Civil War & the Global Threat of Pandemics

Paul H. Wise & Michele Barry

Abstract: This essay confronts the collision of two potential global threats: the outbreak of infectious pandemics and the outbreak and protraction of civil wars. Specifically, it addresses the potential that civil wars can elevate the risk that an infectious outbreak will emerge; the possibility that civil wars can reduce the capacity to identify and respond to outbreaks; and the risk that outbreaks in areas of civil conflict can generate political and security challenges that may threaten regional and international order. Both global health governance and international security structures seem inadequate to address the health and security challenges posed by infectious outbreaks in areas of civil conflict. New approaches that better integrate the technical and political challenges inherent in preventing pandemics in areas of civil war are urgently required.

The West African Ebola outbreak is thought to have begun with little Emile Ouamouno, a one-year-old who died in December 2013 in the village of Melian- dou, Guinea. By the time the outbreak was declared PAUL H. WISE is the Richard E. over in January 2016, an official tally of some 11,300 Berhman Professor of Child Health people had died and more than 28,000 had been in- and Society and Professor of Pe- fected in the three most heavily affected countries: diatrics and Health Policy at the Guinea, Sierra Leone, and Liberia. The economies and Stanford University School of health care systems of these three countries had been Medicine, and Senior Fellow at devastated, which in turn resulted in more suffering the Freeman Spogli Institute for International Studies at Stanford and countless lost lives. The armed forces of the af- University. fected countries had been mobilized, as were units from the United Kingdom and the United States, in- MICHELE BARRY is Senior Associ- cluding the famed 101st Airborne Division (Air As- ate Dean of Global Health, Direc- tor of the Center for Innovation in sault). While the impact of this outbreak in death, Global Health, Professor of Med- human suffering, and fear was catastrophic, this es- icine, Senior Fellow at the Woods say raises the question of what might the impact of Institute, and Senior Fellow at the an Ebola outbreak have been if it had occurred not in Freeman Spogli Institute at Stan- 2013 but in 2000, when Guinea, Sierra Leone, and Li- ford University. beria were embroiled in brutal civil wars. This ques- (*See endnotes for complete contributor tion seems particularly relevant given that the 2013 biographies.) Ebola outbreak exposed current global health struc-

Downloaded from http://www.mitpressjournals.org/doi/pdf/10.1162/DAED_a_00460 by guest on 23 September 2021 Civil War & tures as largely incapable of operating ef- epidemiology and politics that always ac- the Global fectively in countries with poor health sys- companies a global infectious outbreak. The Threat of Pandemics tems and weak governance, characteristics Centers for Disease Control and Prevention likely to be particularly apparent in areas (cdc) defines a pandemic as “an epidem- plagued by protracted civil unrest. In such ic that has spread over several countries or settings, global health imperatives may col- continents, usually affecting a large num- lide with global security structures, a colli- ber of people.”1 It involves epidemiology sion for which neither arena of global gov- since it has at its core the dynamics of dis- ernance appears adequately prepared. ease progression and infectious transmis- The interaction between epidemic dis- sion from individual to individual. Howev- ease and civil conflict has evolved dramat- er, the definition also recognizes that pan- ically over the centuries. The past sever- demics must cross national borders, an al decades have witnessed the predomi- inherent acknowledgement that pandem- nance of protracted civil conflicts that do ics relate to notions of state sovereignty and not readily conform to traditional bound- governance. aries between war and peace. Rather, pro- The majority of the approximately four longed, churning instability has become hundred emerging infectious diseases that common with periods of relative calm in- have been identified since 1940 have been terrupted by eruptions of violent, often zoonoses: infections that have been trans- vicious conflict. While the diseases asso- mitted from animals to humans. Common- ciated with these new forms of war have ly, the infectious agent lives in the animal also evolved, what has altered the threat host, often without causing any discernable of war-generated epidemics forever is the disease. The animals thereby serve as a “res- unprecedented potential for rapid dissem- ervoir” for the infectious agent. The jump, ination throughout the world. or “spillover,” from the animal host to hu- This discussion is premised on the dual man populations can be due to an unusual- recognition that global infectious pandem- ly close contact, such as slaughtering an in- ics have the potential to threaten the inter- fected animal, and may be associated with national order and that civil wars may en- a mutation in the infectious microbe mak- hance the risk that such a pandemic will ing it more likely to infect a human host. emerge and have a global impact. Three re- Human immunodeficiency virus (hiv) is lated mechanisms are of central concern: the iconic disease that emerged from a spill- 1) the possibility that civil wars can elevate over from a simian host. Emergent infec- the risk that an infectious outbreak with tious diseases can also require arthropod pandemic potential will emerge; 2) the pos- blood-seeking insects for transmission such sibility that civil wars can reduce outbreak as mosquitoes or ticks. Mosquitos serve as surveillance and control capacities, result- “vectors” in such diseases as malaria, yel- ing in silent global dissemination; and low fever, and zika, and involve cycles of 3) the potential that infectious outbreaks mosquito transmission from reservoir an- emerging in areas plagued by civil conflict imals with spillover to humans. The emer- can generate complex political and security gence of a zoonosis with the potential for challenges that can threaten traditional no- pandemic spread generally occurs when tions of national sovereignty and enhance there is a change in the long-standing ecol- incentives for international intervention. ogy of human-animal-infectious agent interaction. The importance of this ecolog- Interestingly, the very definition of a pan- ical relationship has been recognized by demic foretells the intricate dance between the One Health Initiative, which links hu-

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Downloaded from http://www.mitpressjournals.org/doi/pdf/10.1162/DAED_a_00460 by guest on 23 September 2021 man and veterinarian medicine within a as Severe Acute Respiratory Syndrome Paul H. new ecological framework.2 For the most (sars) in Southern China and h1n1 in- Wise & Michele part, human factors, such as the expansion fluenza likely in Mexico, there is consid- Barry of human populations into previously for- erable overlap between the hotspots for ested areas, domesticated animal produc- emerging infections and hotspots of civil tion practices, food shortages, and alter- conflict. Of particular concern is the role ations in water usage and flows, have been of social disruption and forced migration the primary drivers of altered ecological in generating the conditions for pandem- relationships. There is also substantial evi- ic emergence. Combat operations and the dence that climate change is reshaping eco- threat of violence invariably generate the logical interactions and vector prevalence migration of civilian populations into saf- adjacent to human populations.3 Enhanced er locations, often into forested or other re- trade and air transportation have increased mote areas where intense interaction with the risk that an outbreak will spread wide- wildlife populations is more likely. In addi- ly. While infectious outbreaks can be due tion, the search for food among these refu- to all forms of infectious agents, including gee populations may require the hunting of bacteria, parasites, and fungi, viruses are of nontraditional forms of wildlife, such as ro- the greatest pandemic concern. dents, bats, or primates, which can greatly New infectious agents can emerge any- elevate the risk of zoonotic spillover. For ex- where humans inhabit the planet. Howev- ample, the dangerous Ebola, Marburg, and er, the science of emerging infections sug- Nipah viruses are carried by bats, and the vi- gests that the greatest danger of pandemic rus that caused the 2002–2004 sars out- generation lies in tropical and subtropical break was also likely transmitted by bats. regions where humans and animals, par- While the emergence of new human dis- ticularly wild animals, are most likely to eases is not confined to areas plagued by interact. Recent analyses have suggested war, populations fleeing civil war may also that the “hotspots” for emerging infec- intensify the early human-to-human trans- tious diseases lie in Eastern China, South- mission of emerging infections.6 Refugee east Asia, Eastern Pakistan, Northeast In- camps are usually characterized by people dia and Bangladesh, Central America, and living in extremely close proximity to one the tropical belt running through Central another, often crowded into makeshift shel- Africa from Guinea, through Nigeria, the ters, elevating the risk of transmission. In Democratic Republic of the Congo (drc), addition, malnutrition and poor hygiene Rwanda, and Burundi, and into Ethiopia.4 and sanitation can also elevate the risk of These hotspots have been identified using infection. However, while the impact of civ- sophisticated analytic models but general- il conflict on pandemics may elevate the risk ly approximate areas where new or intense that a new infectious disease will emerge, human activity coincides with high wild- the greater concern is that civil conflict will life and microbial diversity. This elevated undermine the local and global capacity to risk includes both the initial spillover of control it. infectious agents from animal to human populations as well as the potential for There exists a significant technical capaci- substantial human-to-human transmis- ty to ensure that a local infectious outbreak sion due to local conditions, such as hu- is not transformed into a global pandemic. man population density and movement.5 There also exists a global health governance Although serious pandemics have system charged with employing this techni- emerged from mid-income countries, such cal capacity whenever and wherever such an

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Downloaded from http://www.mitpressjournals.org/doi/pdf/10.1162/DAED_a_00460 by guest on 23 September 2021 Civil War & outbreak emerges. The control of infectious quires a strong and methodical surveillance the Global outbreaks requires some level of organized infrastructure.8 The routine collection and Threat of Pandemics collective action; in essence, effective gov- testing of samples drawn from domesticat- ernance. Together, the technical and gov- ed poultry and pig production chains can ernance requirements for controlling the provide early warning of a potential for risk of pandemics can be grouped into three spillover into human populations. Similar- general categories: prevention, detection, ly, the sampling of wildlife, including po- and response. tential vectors, such as mosquito or rodent Prevention requires the provision of im- populations, is also a standard mechanism munization, when effective vaccines exist. for identifying the presence of worrisome Immunization programs for polio, cholera, infectious agents. The detection of actual yellow fever, measles, and a variety of oth- animal and human illnesses requires a clin- er infectious illnesses are effective and rel- ical capacity that can both identify worri- atively inexpensive. Immunization to pre- some cases and report this concern to the vent influenza is a special case: while gen- appropriate pandemic alert systems. Clini- erally effective, it must be given annually cally distinguishing illnesses that may be of since the immunization is directed at only pandemic potential is not easy, since many one strain of virus, which varies from year such illnesses can present with relatively or- to year. Prevention also includes efforts to dinary symptoms, such as fever and mal- alter behaviors that elevate the risk that an aise. Indeed, potentially pandemic influen- infectious agent will jump from animals to za generally presents as “the flu.” humans. For example, a behavioral modi- The development and maintenance of fication campaign was implemented in Si- animal surveillance systems in areas char- erra Leone to confine an outbreak of Lassa acterized by civil conflict and poor securi- fever, relying primarily on disseminating ty can be extremely challenging. Routine information on how to avoid exposures to animal surveillance demands substantial rodents, the primary carrier of the Lassa vi- logistical chains and careful organization- rus.7 Educational efforts have sought to re- al controls. The sampling protocols can- duce the risk of the animal-to-human spill- not be based on isolated events or conve- over associated with the hunting of non- nience samples but must be representative domesticated tropical animals, generally of the actual environment to be of any prac- referred to as “bushmeat,” which in many tical utility. In addition, animal surveillance areas includes monkeys and bats. These ed- systems require adequate laboratory capac- ucational efforts have been targeted at re- ity to identify the viruses or other infectious ducing hunter exposure to the blood and agents of concern. Because most laborato- other bodily fluids of bushmeat prey, as ries capable of performing the requisite some communities may depend upon the tests are located in capital cities or regional hunting of bushmeat for nutrition or live- centers, this generally means that samples lihood. must be routinely collected and transported The early detection of an infectious out- from relatively remote sites and travel sub- break with pandemic potential is a funda- stantial distances. In many low-resource ar- mental component of any pandemic con- eas, even relatively sophisticated labora- trol capacity. However, the requirements tories may not have the requisite biosafe- for an effective detection capability are both ty capabilities to test for highly infectious technically and organizationally complex. agents. While possible, overcoming these The early detection of worrisome infectious logistical challenges in insecure areas can agents in animal or human populations re- be exceedingly difficult.

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Downloaded from http://www.mitpressjournals.org/doi/pdf/10.1162/DAED_a_00460 by guest on 23 September 2021 Detection may also require the abili- al health systems were a key contributor to Paul H. ty to quickly discern patterns of atypical the deeply flawed response to the outbreak. Wise & Michele case presentation. Epidemiological inves- While these reports called for enhanced fi- Barry tigations in which contact tracing can be nancial support for strengthening national conducted and suspicious clusters of cases health systems, current global health secu- can be distinguished from the background rity structures continue to place the respon- noise of common illnesses may not be fea- sibility for improving these systems on the sible in conflict areas. It is also important national governments themselves. Clear- to remember that the practical utility of ly, this approach is problematic for coun- early detection will be heavily dependent tries plagued by civil war. It is useful, there- on the speed with which systems of sur- fore, to examine these global health securi- veillance can operate. Accordingly, strong, ty systems and why they rely so heavily on responsive communication networks are the commitment and capacities of the af- essential for early outbreak detection, both fected countries and why this is not likely for coordinating the requisite investiga- to change anytime soon. tions as well as for integrating data derived from various sources. Civil wars common- The only comprehensive global frame- ly disrupt traditional means of communi- work for pandemic detection and control cation. New strategies that utilize satellite is the legally binding international trea- or other technologies to link remote or in- ty, the International Health Regulations secure areas to surveillance are needed. (ihr).10 Currently covering 196 nations, the The Ebola virus outbreak in West Afri- ihr have their historical roots in the ear- ca exposed glaring weaknesses in the glob- ly nineteenth-century sanitary codes, deal strategy to control pandemic outbreaks veloped after a series of cross-border epi- in areas with minimal public health ca- demics in Europe underscored the need for pacity. The local failures were myriad and international public health standards and have been documented by a variety of post- cooperation. The United Nations created outbreak assessments.9 The detection and the World Health Organization (who) in reporting of the outbreak was delayed for 1948, which had built into its constitution months because of inadequate health ser- the authority to craft regulations directed vices and poor communication among at “sanitary and quarantine requirements clinicians and public health authorities. and other procedures designed to prevent Health facilities were quickly overwhelmed the international spread of disease.” In 1951, by the rising number of patients with Eb- the who consolidated a number of earlier ola and large numbers of health workers health agreements and renamed them the became ill and died. Many facilities were International Sanitary Regulations (isr). A shuttered or restricted their services to pa- revision of the isr was adopted in 1969 and tients with suspected Ebola infection. Con- renamed the International Health Regula- sequently, it is likely that, during the out- tions. Significantly, theihr were, as were break, many more deaths resulted from their predecessor agreements, directed at inadequate care for patients with illnesses the dual goals of reducing the internation- other than Ebola. The health care provid- al spread of infectious diseases and the ed to patients with Ebola was substandard avoidance of unnecessary burdens on the early on, which not only led to unnecessary flow of international trade and transpor- deaths, but also enhanced transmission. tation. However, the inadequacies of the Virtually all the post-Ebola appraisals ihr during several outbreaks in the early were quick to emphasize that weak nation- 1990s prompted the who to initiate a re-

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Downloaded from http://www.mitpressjournals.org/doi/pdf/10.1162/DAED_a_00460 by guest on 23 September 2021 Civil War & vision process in 1995. However, the revi- Concern (pheic), which is a formal call to the Global sions only moved to the front burner af- adopt who recommendations and to coor- Threat of Pandemics ter the 2002 outbreak of sars, which be- dinate the responses of member states, but, gan in the Guangdong Province of China significantly, it imposes no binding obliga- but quickly spread to some two dozen coun- tions on state action.12 tries in North America, South America, Eu- The ihr (2005) required that states re- rope, and Asia and had an estimated short- port the status of their health capacities and term, economic cost of about $50 billion.11 imposed a deadline of 2012 for all states to China’s failure to report the outbreak in a have in place the necessary capacities to de- timely manner and prolonged resistance tect, report, and respond to local infectious to international cooperation in mounting outbreaks. However, only a small percent- a global response only underscored the ur- age of state parties reported meeting these gent need to revise the ihr. requirements and almost one-third did not The revision was ultimately adopted in even provide the requisite capacity infor- 2005 and addressed several significant de- mation when surveyed by the who. Prior ficiencies, including the glaring problem to the outbreak, Sierra Leone reported in- that the ihr only attended to outbreaks adequate progress in meeting ihr capaci- from three diseases: cholera, yellow fever, ty goals; Liberia and Guinea were among and plague. Interestingly, these were the the countries that failed to report their sta- same three diseases that were addressed tus.13 Post-Ebola recommendations have by the original European sanitary regula- stressed the need for greater external as- tions adopted in the 1800s. The 2005 revi- sessment and the linkage of international sion expanded the purview of the ihr to funding for health system strengthening include all outbreaks that posed a “public to more rigorous evaluation and report- health risk” or a “public health emergen- ing.14 However, even with enhanced fund- cy of international concern.” In addition, ing and accountability provisions, the low the 2005 revision allowed the who to ob- probability that weak states, and particu- tain and use data from nongovernmental larly those plagued by civil conflict and pro- sources. This provision recognized that in- tracted violence, will make the requisite im- formation from member states might not provements in their own health systems be accurate, either because of inadequate represents a dramatic vulnerability in the data collection capabilities or in response global health security system. to the political and economic repercussions states might encounter by reporting an out- Despite calls to strengthen general health break. The 2005 revision also attempted to system capacities, a major component of address the fact that many national public foreign assistance initiatives concerned health systems do not possess even the most with pandemic control are focused specif- rudimentary capabilities to detect, respond ically on enhancing just those capabilities to, and report an infectious outbreak. How- needed for pandemic surveillance, detec- ever, the burden was placed on the states tion, and response. The United States Agen- themselves to improve their systems and re- cy for International Development (usaid) port progress on a regular basis to the who. and the cdc have been working to improve Additionally, the 2005 revision inserted local pandemic detection and response ca- concerns for human rights into the regu- pacities by directing resources and training lations and created a mechanism by which to twenty countries thought to be at high the who could authorize the declaration of risk for pandemic emergence, including a Public Health Emergency of International the Democratic Republic of the Congo.15

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Downloaded from http://www.mitpressjournals.org/doi/pdf/10.1162/DAED_a_00460 by guest on 23 September 2021 The Emerging Pandemic Threats Program tain areas, a running insurgency.18 In July Paul H. (ept-2) has supported a variety of projects 2014, a Liberian-American diplomatic trav- Wise & Michele designed to develop data and build capac- eler, who had been infected with Ebola vi- Barry ity in surveillance and response. A broad- rus in Liberia, traveled to Lagos, a mega- er global effort, the Global Health Secu- city of almost eighteen million people. The rity Agenda, has been endorsed by the g7 virus was subsequently transmitted to oth- (Canada, France, Germany, Italy, Japan, the ers in Lagos and in Port Harcourt, the home United Kingdom, and the United States) of Nigeria’s international oil refining and as means for bringing together a variety of export industry. However, just two months health and veterinary agencies within a One after the first case was identified, no new Health framework and improving account- cases were reported in Nigeria. This expe- ability for the status of national pandemic rience would suggest that, indeed, pandem- control systems.16 ic control can be successfully implement- The underlying premise of these fo- ed in countries with weak health systems cused initiatives in places like the drc is and low government effectiveness. Howev- that what is needed for effective pandemic er, on deeper examination, there were spe- control is not good governance per se but cial conditions in Nigeria that may not be “good enough governance” or “strategic representative of conditions in other areas governance” in which the minimal gover- of weak governance or chronic conflict. Be- nance and security conditions required by cause Nigeria was one of the few remain- the technical elements of pandemic con- ing countries in the world still experiencing trol are met.17 Strategic governance for cases of polio, a significant investment had health service provision contends that been made beginning in 2012, particularly each technical intervention places dis- by the Bill and Melinda Gates Foundation, tinct burdens on governance and system to develop an extensive system of polio sur- capacity. For example, an immunization veillance and response.19 With the detec- program may require different things from tion of the first case of Ebola, this system of local governance capacities than a mater- highly trained supervisory staff, hundreds nal mortality reduction initiative. This of field operatives, communication net- may clarify why, in unstable regions, spe- works, and specialized equipment were im- cific domains of health outcomes can im- mediately shifted to support the outbreak prove while others plateau or worsen. For control apparatus in the affected Nigerian example, Liberia experienced dramatic de- cities. The presence of this polio eradication clines in young-child mortality over the infrastructure was likely crucial to the rela- past decade. However, its response to Ebo- tively swift and successful response to Ebola la was catastrophically ineffective. Oth- in Nigeria. This would suggest that a strate- er examples include the success of large- gic investment in specific health and gover- scale antiretroviral medication programs nance capacities can prove effective in cer- in the central plateau of Haiti, immuniza- tain settings. Similar polio eradication ini- tion programs in Somalia, and dramatic tiatives have been developed in Pakistan, reductions in maternal-to-child transmis- another country plagued by civil conflict. sion of hiv infection in Zimbabwe. Nevertheless, it is useful to note that the po- Support for the potential utility of a stra- lio eradication infrastructure required con- tegic approach has also come from the suc- siderable time to develop and substantial cessful containment of Ebola in Nigeria, a external investments. Therefore, the Ni- country deeply troubled by corruption, gerian experience with Ebola may not re- political and ethnic tensions, and, in cer- flect the likely capacities of other political-

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Downloaded from http://www.mitpressjournals.org/doi/pdf/10.1162/DAED_a_00460 by guest on 23 September 2021 Civil War & ly complex, low-income countries attempt- about the Ebola outbreak in West Africa the Global ing to control a serious infectious outbreak. were laid at the doorstep of the affected Threat of Pandemics national authorities and the regional who The vulnerability generated by weak na- committees, which were highly concerned tional health capacities is not confined to about the economic and social implica- issues of health. Rather, if there is a per- tions of reporting an outbreak.21 ception that a country is either unwilling Countries experiencing civil wars may or unable to deal with a potential pandem- not be particularly worried about disrup- ic outbreak, a series of serious security con- tions to tourism or international trade. cerns can quickly emerge. The ihr do not However, the deference to sovereignty require that any state implement who rec- claims in the ihr has also had a significant ommendations, permit entry to who tech- impact on the detection and response to in- nical teams, or accept international assis- fectious outbreaks in these areas. Syria had tance. “Soft” compliance mechanisms have not reported a case of polio since 1999. In been adopted that attempt to enhance the 2013, health workers began to see young incentives for state compliance, but can- children presenting with the kind of paral- not compel fulfillment ofwho guidance. ysis that is generally associated with a polio For example, the who can publicize the outbreak, which is highly contagious and failure of states to abide by who recom- is considered a public health emergency. mendations and openly articulate the pre- However, the government and the region- sumed consequences of resisting interna- al who office have been intensely criticized tional assistance. The ihr also permit the for their slow and uneven responses.22 It who to seek data on outbreaks from non- was noted early in the outbreak that the cas- governmental sources for the first time.20 es were concentrated in areas controlled by This provision was adopted, after consider- groups opposed to the Assad regime. This able negotiation with concerned state par- was not particularly surprising given that ties, in the hope of encouraging host states these areas had experienced a deterioration to provide more timely and accurate data in general living conditions as well as the on the status of outbreaks. There have also government’s abandonment, if not active been recent efforts to enhance state report- destruction, of sanitation and water sup- ing of health system capacities through sup- plies, two primary means of polio virus dis- plementary independent voluntary assess- semination. In addition, government-spon- ments of countries working through the sored immunization services for children Global Health Security Agenda consortium. had also eroded badly in these areas. The The bottom line, however, is that despite Assad regime has been accused of hesitat- the profound global threat of pandemics, ing to confirm early reports of polio in the there remains no global health mechanism opposition areas and impeding the delivery to force state parties to act in accordance of vaccines and health workers to those lo- with global health interests. Moreover, cations. The who was also criticized for its there also persist inherent disincentives lack of quick response, although its hands for countries to report an infectious out- were somewhat tied by the mandate that it break early in its course. The economic im- act only after receiving the assent of the na- pact of such a report can be profound, par- tional government. Ultimately, with pres- ticularly for countries heavily dependent sure from international health organiza- upon tourism or international trade. Chi- tions and neighbors in the region (Jordan, na hesitated to report the sars outbreak the West Bank, and Israel detected the polio in 2002. Tragic delays in raising the alarm virus in sewage presumably coming from

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Downloaded from http://www.mitpressjournals.org/doi/pdf/10.1162/DAED_a_00460 by guest on 23 September 2021 Syria), a major polio vaccination campaign in providing the health service in question, Paul H. was implemented involving the govern- the state’s political legitimacy may be en- Wise & Michele ment health infrastructure in the south of hanced. In this manner, the role of health Barry the country and a consortium of both inter- services in creating state legitimacy can be national and local nongovernmental orga- intensely dynamic, particularly in violently nizations in the north. This strategy appar- contested political environments. ently terminated the outbreak and remains Regardless of how extensive the capac- the only way to provide immunizations in ities of a health system appear on paper, both governmental-held and rebel-con- the actual effectiveness of the system will trolled areas of Syria.23 almost always rest on whether the citizen- The Syrian polio outbreak is an impor- ry perceives the system as legitimate.24 The tant reminder that health interventions, lack of political legitimacy can undermine though technical in nature, can be trans- a health system’s response in several criti- formed into political currency when cer- cal ways: First, diminished political legiti- tain conditions are met. At the most basic macy can threaten informational authority. level, the destruction or withholding of es- As was seen early in the Ebola outbreak, the sential health capabilities can be used to co- official attempts to disseminate informa- erce adversaries into political compliance, tion on the nature and prevention of Ebo- if not complete submission. The purpose- la transmission were profoundly weak- ful Syrian and Russian bombing of hospi- ened by a general distrust of the state as a tals and other health facilities in the be- source of reliable information. While con- sieged city of Aleppo is a representative, if cerns regarding inappropriate cultural, lin- especially brutal, expression of this explic- guistic, and literacy levels of the informa- it strategy. The intention was clearly to in- tion likely also contributed to the lack of ef- flict profound suffering and amplify casu- fect, the core problem was less the content alties: one dead doctor can result in many than the source of the information. The au- more dead among the unattended injured. thority of the state to provide critical, life- There are also important, though more or-death information had to confront the subtle mechanisms by which the provision fact that many at greatest risk of being in- of health services can take on an intensely fected by the Ebola virus did not believe the political character. In particular, three gen- state prioritized their interests. Second, un- eral conditions can define how health inter- der certain conditions, local communities ventions ultimately relate to perceptions of may attempt to insulate themselves from political legitimacy: First, the population state authority. Particularly, where states must perceive that an infectious outbreak have been perceived as predatory, the “art represents a major threat. Second, the pop- of not being governed” can produce pro- ulation must see health services as techni- tective practices and local political impuls- cally capable of successfully combatting the es that can expressly, or at least effectively, perceived threat. Third, the state must be shield populations from state control, a sit- viewed as being responsible for the provi- uation that can undermine even the best- sion of this technical capacity. When these intentioned public health initiatives.25 conditions are met, the political legitima- Third, and perhaps most important, weak cy of the state will almost always be in play; political legitimacy can make state-propa- political legitimacy can be undermined by gated health activities increasingly reliant nonprovision. Alternatively, when the state on coercion. Public health responses to an or its proxy, such as a un agency or non- infectious outbreak will almost always de- governmental organization, is successful pend upon public compliance with behav-

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Downloaded from http://www.mitpressjournals.org/doi/pdf/10.1162/DAED_a_00460 by guest on 23 September 2021 Civil War & ioral recommendations, such as quaran- numerous examples of this dynamic. Most the Global tine. In settings of high political legitima- Jihadist forces in Iraq and Syria have sup- Threat of Pandemics cy, such compliance will reflect normative ported immunization campaigns. Most Tal- respect for state authority on such matters iban fighters in Afghanistan have generally as public health. However, when legitima- not attacked local health clinics, even those cy is low, normative respect can be replaced constructed by U.S. forces or supported by by skeptical noncompliance. In a setting of external nongovernmental organizations. potential pandemic dissemination, skep- However, there are also many counter- tical noncompliance may not be tolerated examples in which the struggle for legiti- by the state or threatened regional or inter- macy has put health workers at risk of po- national entities, and coercive tactics may litically motivated violence, as is evident by seem the only recourse. In such situations, the continued targeting of Pakistan’s polio responsibility for the management of the immunization programs.29 The U.S. Cen- outbreak may shift from the ministry of tral Intelligence Agency’s use of a Pakistani health to the army.26 This shift in strategic physician masquerading as an immuniza- authority was made clear to a global audi- tion worker to ascertain the whereabouts ence when Liberian security forces were uti- of Osama Bin Laden only enhanced the po- lized to impose what ultimately became a litical utility of these attacks on state-spon- failed attempt to quarantine the crowded, sored vaccination teams. In Syria, the Assad impoverished West Point neighborhood of regime and allied Russian forces have tar- Monrovia, Liberia, at the height of the Ebo- geted health facilities and personnel in or- la outbreak.27 der to deprive civilian populations of ade- The political currency of health ser- quate health care and thereby amplify the vices, particularly in areas of civil conflict, suffering and death associated with contin- can also be wielded as a weapon of politi- ued resistance. cal advantage. This is most apparent when Global pandemic control systems respect a service of clear political value is provided national sovereignty; infectious outbreaks or withheld based on the behaviors of lo- do not. This mismatch of policy and biolo- cal populations. Standard counterinsurgen- gy is an inherent vulnerability of the current cy doctrine has made the provision of pub- international health governance infrastruc- lic goods, such as valued health services, a ture, which can create a level of profound means of generating strategic support for a unpredictability in how states respond to combatant force, the state, or its proxies.28 pandemic threats. While these questions When the conditions of perceived infec- relate generally to the control of pandem- tious threat, effective technical capacity, ics, they have special meaning in the con- and state responsibility for access to this ca- text of civil conflict and violent political in- pacity are met, the direct provision of this stability. Sovereignty is best considered as service will tend to enhance the political le- a composite of several component political gitimacy of the state. However, when the standards.30 Domestic sovereignty refers state fails to provide the service, its politi- to the state’s performance in regulating vi- cal legitimacy can be diminished. It should olence and exercising authority within its not be surprising, therefore, that health ser- borders. Westphalian sovereignty refers to vices may become vulnerable to assault by the autonomy of the state and its ability to forces that oppose the state. Conversely, at- exercise power without interference from tacks on services of high value to local com- external forces. International legal sover- munities could undermine the legitimacy eignty involves the formal recognition of of the forces opposed to the state. There are the state within the administration of in-

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Downloaded from http://www.mitpressjournals.org/doi/pdf/10.1162/DAED_a_00460 by guest on 23 September 2021 ternational organizations and law. Interde- described as the conflict between two log- Paul H. pendence sovereignty relates to the ability ics: the logic of appropriateness and the log- Wise 34 & Michele of states to control threats emanating from ic of consequences. The logic of appropri- Barry regional or global processes that transcend ateness emphasizes legal sovereignty and national borders, such as climate change, compliance with rules, roles, and behav- air pollution, or the globalization of food iors prescribed in international agreements. production. By some measures, the vulnera- The ihr reflect this approach, relying on bilities and contradictions within the global the approval of all 196 member states. The health security regimes reflect tensions be- logic of consequences recognizes the prag- tween these different forms of sovereignty. matic behavior of political actors to maxi- A series of calls for reforming global mize their own interests. While the logic health governance have emphasized the of appropriateness and the logic of conse- inherent interdependence of states in ad- quences are not incompatible, they can of- dressing a variety of public health chal- ten diverge, particularly when domestic po- lenges.31 Particularly, in the wake of the litical concerns begin to dominate interna- Ebola outbreak in 2013–2014, the risk of tional behavior. rapid cross-border dissemination of infec- The fear of pandemic infectious disease tious diseases has questioned the ihr’s ba- can be a powerful driver of domestic poli- sis in legal and Westphalian sovereignty tics. In response to the fears generated by claims, claims that may represent an out- the Ebola outbreak in 2014, a number of moded map for navigating effective glob- countries imposed harsh travel restrictions al pandemic control. The argument sug- even though they violated protocols delin- gests that the epidemiologic challenge to eated in the ihr. In the United States, public interdependence sovereignty is so signifi- fear and the resultant political environment cant that some arenas of power tradition- set the stage for several state governors to ally rooted in legal or Westphalian sover- disregard technical recommendations from eignty should give way to shared, global the cdc and implement their own severe governance processes.32 quarantine procedures. In such an atmo- The case for enhancing the power of glob- sphere, domestic political pressures in ac- al health agreements seems most compel- cordance with the logic of consequences ling for risks emanating from areas of vio- may result in meaningful departures from lent conflict. Here, minimal health system global health agreements developed in ac- capacity, poor security, and suspect politi- cordance with the logic of appropriateness. cal legitimacy represent a heavily compro- It is also important to keep in mind the mised domestic sovereignty. The mainte- speed with which pandemics and, signifi- nance of traditional Westphalian sover- cantly, the fear of pandemics can spread. As eignty claims in the face of a weak domestic these fears take hold, neighboring countries sovereignty reality may prove particularly as well as states with a global military reach counterproductive, at least in meeting the may experience growing domestic pres- requirements for pandemic control.33 sure to intervene. These pressures could This misalignment not only may make force international actors to depart quick- the global response to pandemic risk less ly from extant global health protocols and effective, it may also create a potential gap resort to direct intervention. Even if these between actions sanctioned by current interventions are directed at technical and global health governance agreements and health personnel, in areas of conflict, this the homeland security interests of region- assistance will likely require sufficient mil- al and global powers. This tension has been itary capability to ensure the security of the

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Downloaded from http://www.mitpressjournals.org/doi/pdf/10.1162/DAED_a_00460 by guest on 23 September 2021 Civil War & requisite health personnel and activities. As curity and, ultimately, the demands of in- the Global was noted in Haiti and Liberia, this securi- ternational order. The unpredictability of a Threat of Pandemics ty role can extend beyond the usual logisti- serious infectious outbreak, the speed with cal responsibilities the military may have which it can disseminate, and the fears of in settings of complex humanitarian emer- domestic political audiences can together gencies. Moreover, because most civil wars create a powerful destabilizing force. Cur- reflect the proxy involvement of regional rent discussions regarding global health or global powers, the ad hoc nature of such governance reform have largely been pre- health-instigated interventions could play occupied by the performance and intricate into complex geopolitical agendas and po- bureaucratic interaction of global health tentially trigger unpredictable and destabi- agencies. However, what may prove far lizing military confrontations. more critical may be the ability of global The fundamental concern is that the health governance structures to recognize global health security regimes may not at- and engage the complex, political realities tend to the requirements of homeland se- on the ground in areas plagued by civil war.

endnotes * Contributor Biographies: PAUL H. WISE is the Richard E. Berhman Professor of Child Health and Society and Professor of Pediatrics and Health Policy at the Stanford University School of Medicine, and Senior Fellow at the Freeman Spogli Institute for International Studies at Stanford University. He is the author of “The Epidemiologic Challenge to the Conduct of Just War: Confronting Indirect Civilian Casualties of War” (2017) and, with Gary Darmstadt, of “Confronting Stillbirths and Newborn Deaths in Areas of Conflict and Political Instability: A Neglected Global Imperative” (2015) and “Strategic Governance: Addressing Neonatal Mor- tality in Situations of Political Instability and Weak Governance” (2015). MICHELE BARRY is Senior Associate Dean of Global Health, Director of the Center for In- novation in Global Health, Professor of Medicine, Senior Fellow at the Woods Institute, and Senior Fellow at the Freeman Spogli Institute at Stanford University. She is a past President of the American Society of Tropical Medicine and Hygiene and a member of the National Academy of Sciences, Medicine, and Engineering. She has published articles in such journals as American Journal of Tropical Medicine and Hygiene, Academic Medicine, and The New England Jour- nal of Medicine. 1 Centers for Disease Control and Prevention, “An Introduction to Applied Epidemiology and Biostatistics,” Principles of Epidemiology in Public Health Practice, 3rd ed. (Atlanta: U.S. Depart- ment of Health and Human Services, 2012), http://www.cdc.gov/ophss/csels/dsepd/ss1978/ lesson1/section11.html. 2 Centers for Disease Control and Prevention, “One Health,” https://www.cdc.gov/onehealth/ (accessed October 10, 2016). 3 Brian L. Pike, Karen E. Saylors, Joseph N. Fair, et al., “The Origin and Prevention of Pandemics,” Clinical Infectious Diseases 50 (12) (2010): 1636–1640. 4 Kate E. Jones, Nikkita G. Patel, Marc A. Levy, et al., “Global Trends in Emerging Infectious Diseases,” Nature 451 (2008): 990–993. 5 Stephen S. Morse, “Factors and Determinants of Disease Emergence,” Revue Scientifique et Tech- nique 23 (2) (2004): 443–451. 6 Stewart Patrick, “Infectious Disease,” in Weak Links: Fragile States, Global Threats, and International Security (Oxford: Oxford University Press, 2011), 207–241; Vegard Eldholm, John H. Petters-

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Downloaded from http://www.mitpressjournals.org/doi/pdf/10.1162/DAED_a_00460 by guest on 23 September 2021 son, Ola B. Brynildsrud, et al., “Armed Conflict and Population Displacement as Drivers of Paul H. the Evolution and Dispersal of Mycobacterium tuberculosis,” Proceedings of the National Academy Wise of Sciences 113 (48) (2016): 13881–13886; and Stewart Patrick, “Civil Wars & Transnational & Michele Threats: Mapping the Terrain, Assessing the Links,” Dædalus 146 (4) (Fall 2017). Barry 7 Pike et al., “The Origin and Prevention of Pandemics.” 8 Emily H. Chan, Timothy F. Brewer, Lawrence C. Madoff, et al., “Global Capacity for Emerg- ing Infectious Disease Detection,” Proceedings of the National Academy of Sciences 107 (50) (2010): 21701–21706. 9 Suerie Moon, Devi Sridhar, Muhammad A. Pate, et al., “Will Ebola Change the Game? Ten Es- sential Reforms before the Next Pandemic: The Report of the Harvard-lshtm Independent Panel on the Global Response to Ebola,” The Lancet 386 (10009) (2015): 2204–2221; and David L. Heymann, Lincoln Chen, Keizo Takemi, et al., “Global Health Security: The Wider Lessons from the West African Ebola Virus Disease Epidemic,” The Lancet 385 (9980) (2015): 1884–1899. 10 David P. Fidler, “From International Sanitary Conventions to Global Health Security: The New International Health Regulations,” Chinese Journal of International Law 4 (2) (2005): 325–392. 11 Richard J. Coker, Benjamin M. Hunter, James W. Rudge, et al., “Emerging Infectious Diseases in Southeast Asia: Regional Challenges to Control,” The Lancet 377 (9765) (2011): 599–609. 12 Fidler, “From International Sanitary Conventions to Global Health Security.” 13 Trygve Ottersen, Steven J. Hoffman, and Gaëlle Groux, “Ebola Again Shows the International Health Regulations Are Broken: What Can Be Done Differently to Prepare for the Next Epi- demic?” American Journal of Law & Medicine 42 (2016): 356–392. 14 Lawrence O. Gostin and Eric A. Friedman, “A Retrospective and Prospective Analysis of the West African Ebola Virus Disease Epidemic: Robust National Health Systems at the Foun- dation and an Empowered who at the Apex,” The Lancet 385 (9980) (2015): 1902–1909. 15 United States Agency for International Development, Emerging Pandemic Threats Program–EPT-2: 2014–2019 (Washington, D.C.: United States Agency for International Development, 2014), 1–24, https://scms.usaid.gov/sites/default/files/documents/1864/EPT2-Narrative-508.pdf; and United States Agency for International Development, “Emerging Pandemic Threats,” https://www.usaid.gov/news-information/fact-sheets/emerging-pandemic-threats-program (accessed May 2, 2017). 16 Global Health Security Agenda, “About,” https://www.ghsagenda.org/about. 17 Merilee S. Grindle, “Good Enough Governance Revisited,” Development Policy Review 25 (5) (2007): 553–574; and Paul H. Wise and Gary L. Darmstadt, “Strategic Governance: Address- ing Neonatal Mortality in Situations of Political Instability and Weak Governance,” Seminars in Perinatology 39 (5) (2015): 387–392. 18 Chima Ohuabunwo, Celestine Ameh, Oyin Oduyebo, et al., “Clinical Profile and Contain- ment of the Ebola Virus Disease Outbreak in Two Large West African Cities, Nigeria, July– September 2014,” International Journal of Infectious Diseases 53 (2016): 23–29. 19 Joseph C. Okeibunor, Martin C. Ota, Bartholomew D. Akanmori, et al., “Polio Eradication in the African Region on Course Despite Public Health Emergencies,” Vaccine 35 (9) (2017): 1202–1206. 20 Fidler, “From International Sanitary Conventions to Global Health Security.” 21 Gostin and Friedman, “A Retrospective and Prospective Analysis of the West African Ebola Virus Disease Epidemic”; and Philippe Calain and Caroline Abu Sa’Da, “Coincident Polio and Ebola Crises Expose Similar Fault Lines in the Current Global Health Regime,” Conflict and Health 9 (29) (2015). 22 Calain and Abu Sa’Da, “Coincident Polio and Ebola Crises Expose Similar Fault Lines in the Current Global Health Regime”; and Annie Sparrow, “Syria’s Polio Epidemic: The Suppressed

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Downloaded from http://www.mitpressjournals.org/doi/pdf/10.1162/DAED_a_00460 by guest on 23 September 2021 Civil War & Truth,” The New York Review of Books, February 20, 2014, http://www.nybooks.com/articles/ the Global archives/2014/feb/20/syrias-polio-epidemic-suppressed-truth/?pagination=false. Threat of Pandemics 23 R. Bruce Aylward and Ala Alwan, “Polio in Syria,” The Lancet 383 (9916) (2014): 489–491. 24 Stephen D. Krasner and Thomas Risse, “External Actors, State-Building, and Service Provi- sion in Areas of Limited Statehood: Introduction,” Governance 27 (4) (2014): 545–567. 25 James C. Scott, The Art of Not Being Governed: An Anarchist History of Upland Southeast Asia (New Haven, Conn.: Yale University Press, 2010). 26 Pietro Tornabene, The Military Response to Pandemic: The New Global Threat (Carlisle, Pa.: U.S. Army War College, 2009). 27 Norimitsu Onishi, “Quarantine for Ebola Lifted in Liberia Slum,” The New York Times, August 29, 2014, https://www.nytimes.com/2014/08/30/world/africa/quarantine-for-ebola-lifted -in-liberia-slum.html?mcubz=0. 28 David H. Petraeus and James F. Amos, The United States Army and the United States Marine Corps: Counterinsurgency Field Manual (Kissimmee, Fla.: Signalman Publishing, 2006); and David Kil- cullen, Counterinsurgency (Oxford: Oxford University Press, 2010). 29 World Health Organization, Attacks on Health Care: Prevent, Protect, Provide (Geneva: World Health Organization, 2015); and Slaman Masood, “Polio Team Attacked in Pakistan,” The New York Times, February 14, 2015, https://www.nytimes.com/2015/02/15/world/asia/attack-on-polio -vaccination-team-in-pakistan-leaves-one-dead.html?mcubz=0. 30 Stephen D. Krasner, Sovereignty: Organized Hypocrisy (Princeton, N.J.: Princeton University Press, 1999). 31 Moon et al., “Will Ebola Change the Game?”; Heymann et al., “Global Health Security”; Gos- tin and Friedman, “A Retrospective and Prospective Analysis of the West African Ebola Vi- rus Disease Epidemic”; and Julio Frenk and Suerie Moon, “Governance Challenges in Global Health,” The New England Journal of Medicine 368 (2013): 936–942. 32 Francesco Checchi, Ronald J. Waldman, Leslie F. Roberts, et al., “World Health Organiza- tion and Emergency Health: If Not Now, When?” The BMJ 352 (469) (2016). 33 See Hendrik Spruyt, “Civil Wars as Challenges to the Modern International System,” Dædalus 146 (4) (Fall 2017). 34 James G. March and Johan P. Olsen, Rediscovering Institutions: The Organizational Basis of Politics (New York: The Free Press, 1989).

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