Global Health Challenges for Human Security (Studies in Global Equity)

  • Lincoln Chen,
  • Jennifer Leaning &
  • Vasant Narasimhan
Harvard University Press, 2004 338 pp., paperback, $29.95 ISBN 0674014537 | ISBN: 0-674-01453-7

After 9/11, many Americans asked the question “Why us?” This book is a partial answer. It is a reminder of the complex, multi-faceted nature of 'human security' at a time when 'security' has been hijacked by political conservatives and a sensationalist media to mean one thing: 'the war on terror.'

Security in a globalized world is more than the defense of a 'homeland.' The idea directs us to difficult questions about the implications of unilateral pursuit of economic growth and security by nations (more accurately national elites) acting as though their perceived interests could be pursued without reference to those of others. Such simple-minded perspectives fail to engage with the key problem of the twenty-first century: how do we live together on one small, diverse and increasingly crowded planetary homeland?

This book opens perspectives on this question in relation to health. We live in a world of global risks. The very large scale—events a world away—has serious and immediate implications for our bodies, our intimate selves. Epidemics are societal events: disease is individual, corporeal distress; sexually transmitted diseases are intimate in the extreme. We must think about health and well-being in relation not only to parochial needs but more broadly in relation to the societal nature of security. This is a primitive realization, familiar to our ancestors: the difference is that, unlike them, we can no longer push the afflicted into plague hospitals, retreating like medieval burghers behind the high walls of our city's defences. We must recognize that welfare and security are global common goods and should be common goals.

History is important here—and history is always in danger of being remade in the image of today's monopolists of power. Simon Szreter reminds us how odd it is that only recently have academics and policy-makers linked security explicitly with health. Simply put, they are linked because both are founded in social relations and collective goods. New Deal America and welfarist Europe worked this out over many decades, albeit not without pain and conflict. The challenge now is to advance human security in low-income countries, not least because it is “central to the self-interest of the global public.”

Here are many contested political and ideological issues. Lincoln Chen and Vasant Narasimhan argue that public health, like fire and police protection, is a public good to be provided by government. But that view is contentious at a time when 'government' and 'the state' as actors in human affairs are represented by many opinion-formers as a manifestation of original sin. The silent violence of poverty and inequality are also part of this story. We must recognize that individual ill health—whether obvious as with epidemics associated with poor sanitation, or less obvious, as with urban malnutrition in rich countries—has social, economic and political roots. Speaking of these links between human security and health is to address questions of social justice, right living and enlightened self-interest. Jonas Gahr Støre et al. take this point further, showing how the functioning of markets and global trade depend on health and security.

Human security requires maintenance of 'normality' in a world where abnormality—war, poverty, displacement—is often the norm. Leaning and her co-authors show how people experiencing epidemic violence have an impaired “capacity to re-enter what they vaguely remember to have been a normal moral universe.” This is the “collapse of trust into communal violence,” where state failure transforms group proximity from a positive resource to a threat and—in Bosnia-Herzgovina, Rwanda, Kosovo, and so many places—where “survival was the best that could be achieved. Survival with meaning was too much to ask for.” Leaning et al. suggest that health is one of the most important components of security, along with attachments to home and community. In the absence of these, meaning is put to flight; people seek desperate remedies, from exchanging sex for food to enclosure in hermetically sealed oppositional ideologies which compromise re-entry into an interconnected world.

In one sense, the book is about ideological processes: how to define and elaborate the relation between health and security so that it may become an advocacy tool, grabbing the attention of power-holders. This requires that links be made. Garcia-Moreno examines how the security-health pairing is intimately related to gender issues; Mary Wilson tells of the threats infectious diseases pose for collective security; and a piece by Alex De Waal on HIV-AIDS shows how that epidemic thrives on short- and long-term insecurity and threatens wider long-term security by shortening life expectancy, sundering the bonds of society and threatening the meaning so central to trust. Berlinguer takes us into the realms of international law and regulation, the cumbersome but necessary web of stuff from which any realistic hope for global public goods must be spun.

This spinning must be done in both senses of the word: regulatory and institutional frameworks must be made, and the link between health and security must be spun politically to create those frameworks. There are weak signs that a halting and contested spring may be on the way. UNAIDS, the Global Fund for AIDS, TB and Malaria, the Global Public Health Intelligence Network, these are all in their own ways nascent forms of global health public goods. It is shameful that a brave US initiative, the President's Emergency Plan for AIDS Relief (PEPFAR), stands defiantly outside this global frame. Yet it is significant that this important (if at times ill-organized and poorly integrated) book comes out of a US university—albeit on the eastern seaboard. To this European reviewer, it is some small ground for hope.