Tamara R. Chapman
The James Martin Center for Nonproliferation Studies
Security and Public Health: How and Why do Public Health Emergencies Affect the Security of a Country?
Traditionally, national security is understood to be a collective term for all activities that are brought to bear by a national government to defend its population and territory against threats from hostile nations and subnational groups. These activities encompass both diplomatic and military means. However, as the different parts of the world become more and more interconnected through instant communications and the physical distances between them are bridged by rapid means of transport, it has become widely recognized that traditional concepts of national security are inadequate. As security expert Jessica Mathews wrote in 1989: "The 1990s will demand a redefinition of what constitutes national security. In the 1970s, the concept was expanded to include international economics as it became clear that the U.S. economy was no longer the independent force it had once been, but was powerfully affected by economic policies in dozens of other countries. Global developments now suggest the need for another analogous, broadening definition of national security to include resource, environmental and demographic issues."
Of environmental issues, our view is that infectious diseases of natural etiology are most likely to negatively affect the national security of nations for two major reasons: (1) the movement of bacteria and viruses that cause disease outbreaks are not constrained by national borders so each outbreak potentially has global reach, and (2) the history of past disease outbreaks, as well as the current Human Immunodeficiency virus (HIV) / Acquired Immune Deficiency Syndrome (AIDS) pandemic, clearly demonstrate that they often are more damaging to the populations and economies of nations than any would-be military or terrorist attack.
Public health emergencies potentially can challenge a country's security in many ways. In this short article we discuss four such challenges: (1) a public health emergency can exert enormous pressure on both the micro and macro levels of a country's economy; (2) public health emergencies can lead to social disruption; (3) a government may become destabilized by a health crisis; and (4) a public health disaster can severely affect national defense forces. We close the article by summing up our thoughts in the conclusion.
A public health emergency may negatively affect both the micro and macro layers of national economies.
Microeconomic impacts generated by public health emergencies stem directly from their effects on worker availability and productivity, consumer spending, costs to firms, and domestic spending of governments. In a health emergency, absenteeism in the workplace is likely to markedly increase. The overall availability of workers decreases as they respond to the need to remain home to care for themselves or family members; healthy workers may stay away from their workplaces in an effort to cut down on the probability of contracting disease from contagious co-workers and customers. While it is advisable that workers who experience signs of illness should absent themselves from their work places (and other places where people congregate), during a disease outbreak there is likely to be a substantial number of workers who either imagine that they have signs of illness or feign illness, and thus do not work. Not only does such absenteeism result in lower productivity, but productivity may also suffer because some workers who should stay home due to illness nevertheless report to the workplace where they are unable to fulfill their duties.
Public health emergencies can drastically alter the nature of consumer spending. Some consumers will be sick, and thus will not spend; others will chose to stay away from places of business in order to lessen the probability of contracting disease. In addition, personal spending in such situations often is diverted from the purchase of food, goods, and services to paying for healthcare and medicines. While this might not alter the total amount of consumer spending in a society (though a slowdown in overall consumer spending may ensue as worker productivity and, therefore, wage earning is reduced), the spending that does occur will to a great extent be done in health-related sectors and to the neglect of other goods. This kind of displacement might have serious negative consequences for some national economies.
Firms are likely to be impacted by public health emergencies both immediately, due to the absence or loss of trained workers, and in the longer term as insurance premiums rise. The loss of trained workers would require firms to make expenditures for training new employees to take their places; in case of workers with special skills, costs for training would be substantial. For example, many nations in the developing world are being severely impacted as AIDS causes high rates of illness and death among workers who are in their most productive years; workers in the mid- and upper-management layers of business are especially affected. Training new individuals to work at this level may require even more of a company's resources than training at a low-skill level. Businesses that provide health insurance to their employees and that experience a high rate of illness among its workers are likely to experience increased insurance premiums. It may not be possible for them to raise prices to compensate for higher insurance premiums, at least in the short term, so these losses would have to be taken out of profits.
Domestic government spending on healthcare must increase in a time of public health emergency. Commonly, government spending on healthcare ranges from about 2% of gross domestic product (GDP) in developed countries to 7-14% of GDP in developing countries. These percentages escalate in countries that experience public health emergencies. For example, countries in sub-Saharan Africa that are most affected by the HIV/AIDS epidemic had to spend billions of dollars more to pay for healthcare costs than they had planned for. Also, during the Severe Acute Respiratory Syndrome (SARS) outbreak in 2003, national programs for childhood immunization, AIDS management, tuberculosis, and others suffered or were curtailed because their funding was diverted to pay for unexpected costs that were generated by this newly emerging disease. In general, the need for a government to suddenly have to spend substantial moneys to address a public health emergency will result in it having to divert spending away from planned-for health care and social programs. Additionally, if a government needs to divert funds from a national budget that is already in place to pay for expenses related to addressing a public health emergency, other national programs, including those dedicated to achieving all aspects of national security, are likely to be negatively affected. Thus, in terms of government spending, a public heath emergency negatively affects many aspects of national security by diverting money from economic, social, health, and security programs that aim to maintain an acceptable level of quality of life for the population and guard it from inside and outside threats. The effects of the diversion of government funds to deal with public health emergencies is especially troublesome to security in countries whose economies and political infrastructures are particularly sensitive to upheaval.
Government spending on health emergencies may extend beyond what is required to address the challenges posed by an on-going disease outbreak. In the United States, for instance, much attention has been given since approximately 1996 to preparing for, and defending against, biological weapons that may be deployed by terrorists or adversary governments. Since 2001 alone, the U.S. government has spent in excess of $26 billion on biodefense measures. This indicates that even the fear or anticipation of a possible public health emergency can result in a government spending substantial funds to prepare to meet the exigencies of the hypothetical challenge; the cost of these efforts either add to the federal budget deficit or are diverted from already funded social or security programs. (It bears noting that funding for biodefense has a dual application in that many measures developed and instituted to protect against biological weapons are also useful in protecting against natural infectious diseases. So in the end, they might be worthwhile from the economic view because they prevent disease outbreaks that otherwise would generate high costs related to treatment and rehabilitation.)
Public health emergencies can substantially affect macroeconomic well-being and growth. The macroeconomic impacts can include reductions in foreign investment and decreased GDP levels.
A country that is experiencing an infectious disease epidemic is apt to become unattractive to foreign investors. This may arise as the result of a general feeling of trepidation about the future of an affected nation's economy or specific concerns regarding the potential for trade embargoes to curb disease spread. Trade restrictions directly resulting from attempts to prevent the spread of disease were experienced in Malaysia in 1999, when an outbreak of Nipah virus led to a shutdown of that country's pork exports, as well as in Surat, India, in 1994, when a plague outbreak caused several countries to reject Indian imports. Similarly, seafood exports from Peru were banned as a result of a 1991 outbreak of cholera. In all cases, tourism ground to a halt. When one considers that, economically speaking, tourism is an exported service, these outbreaks had even greater impacts on trade.
As for negative impacts on GDP, HIV/AIDS in sub-Saharan Africa vividly illustrates the potential macroeconomic impact of a pervasive infectious disease. According to World Bank studies, GDP figures for countries that are heavily affected by AIDS are approximately 1% lower than similar countries that have not had to contend with a large epidemic. In Africa, the figures are extreme: AIDS may have cost Namibia nearly 8% of what would without this epidemic have been its GDP in 1996 and Kenya was expected to lose up to 14.5% of its otherwise expected GDP in 2005.
Unchecked disease can wreak havoc on the psychological well-being of a population, leading to social unrest. An environment of stress will impart a climate of instability, which may include the breakdown of normal social structures, such as domestic policing of behavior and traditional family and occupational roles. Communication has changed in recent years, which may further exacerbate the social costs of a health crisis. All of these factors can lead to domestic anxiety.
Again, the HIV/AIDS epidemic illustrates how a public health crisis can impact security, this time in terms of the stability of a society. The generations of orphans that are being created in Africa by the high mortality rate associated with AIDS face little hope for accessing educational and employment opportunities, which may, in turn, lead to uneducated, unemployed youth turning to crime. A corroding society is likely to give rise to an environment in which young people are exploited and radicalized. When young people are marginalized, they can become threats to the security of their own society. Even when a health crisis does not directly cause underlying societal degradation, disease is likely to exacerbate poor conditions that are already present.
During the Surat plague outbreak, social order was challenged by the public health emergency that acerbated already existing ethnic tensions between Muslims and Hindus. As an increasing number people contracted plague, rumors began circulating that Muslim terrorists had poisoned the Surat water supply. As the rumor gained credence among Hindus, widespread rioting broke out. 
A public health crisis that targets a specific demographic group can leave vital roles in a society unfilled. In some nations, for example, a generation of parents has been lost to HIV/AIDS. As a result of these losses, orphan children have little direction, few if any positive role models, and lack a support structure usually provided by family members. The 15-24 age group that is hard-hit by these impacts is also the age group that is most likely to acquire new HIV/AIDS infections. The loss of individuals in this age group strips a society of its future social leaders, military personnel, doctors, nurses, and teachers.
Media pervasiveness in the modern era, especially with the far reach of the Internet, has increased the probability that information about a public health emergency will become widely dispersed among an affected population. In the past, and as was evidenced by the early stages of the SARS outbreak, governments made efforts to hide the presence of a health crisis due to concern about possible negative political and economic implications. The ever-decreasing ability of governments to hide events that take place in a society can both place information that in and of itself may cause worry, discord, and even panic in a population, as well as lead to distrust of the political institutions the public may perceive as being secretive, manipulative, and unresponsive.
The functions of both established and recently formed governments may be threatened by public health emergencies. The U.S. National Intelligence Council has stated that there is an indirect but real connection between high rates of infectious disease and the prevalence of political instability in an area, especially in (but not limited to) developing countries. Were a public health emergency to occur, the feebleness of a weak government may be exploited by dissidents or outsiders, while an established government may lose legitimacy among its own citizenry. In either case, governance would be negatively affected, perhaps to the point of collapse. If the country affected by the disease outbreak was contiguous to, or surrounded by, hostile neighbors, they might well take advantage of the government weakened by a disease outbreak by waging war against it.
In working to create a new framework of government in a region that is recovering from conflict, establishing a dependable public health infrastructure is critical to imparting security, both traditional and nontraditional. In fact, public health events could have either positive or negative effects on national security. In terms of public health emergencies being potentially detrimental to national security, counterinsurgency experts have argued that winning the "hearts and minds" of citizens of an embattled nation is crucial to nation-building, something that would be difficult or impossible to accomplish without those citizens being provided with an adequate level of public health. To this end, some analysts have speculated that interminable substandard health conditions in Iraq are a contributing factor to the Iraqis' unhappiness with the U.S.-backed regime, thus feeding the ongoing and growing insurgency. The converse relationship between security and public health in nation building is illustrated when poor security conditions impede residents' ability to seek medical care, compounded by the failure of health delivery facilities to function properly in insecure areas. Nation-building thus can present a circular challenge; without security, it is difficulty to provide a population with an adequate level of public health, but without adequate public health, achieving sufficient security for nation-building becomes very difficult.
An established government may lose legitimacy during a public health emergency. This might occur if a government were unable to contain an emergency or manage its consequences. One major reason such a situation might come about would be if a government could not provide sufficient security for the first responders and health workers who would be called upon to deal with a budding health emergency. Were this to happen, the perception that the government had lost control of the situation would grow, as would the natural impulse to flee a hopeless situation. The uncontrolled flight of people from a region or city affected by an infectious disease outbreak could have serious consequences for an entire country, or even region, as refugees carry the disease to uninfected areas. One of the ripple effects would be that an ever increasing number of people would perceive the government as powerless and would take matters in their own hands, including repelling refugees with weapons.
A further challenge to government stability arises when affected people are prompted to flee their homeland as fear and sickness saturate the population. Migration of refugees to other countries may cause civil unrest as they attempt to integrate into a new area. This is particularly worrisome in the post-Cold War era, as conflicts tend to be regional, and perhaps neighboring, in nature. An influx of people whose national origins are disagreeable to the receiving country and whose health is actually or perceived to be poor and dangerous will threaten security; conflict may arise between the two states or within the recipient state.
In any case in which members of the governing bodies of a region or nation themselves become victims of a health crisis, policymaking and decisionmaking can become inconsistent and unpredictable. Turnover in policymaking positions will be high as officials are sickened or killed, so changes take place both in the nature of the policies that are created, as well as the fastidiousness with which they are implemented and enforced. A scenario such as this one may have several outcomes that impact security: a sense of chaos in society that arises out of lawmakers' unpredictability; the appearance of vulnerability to insurgents, coup d'état leaders, and external forces; and international marginalization in the global political sphere. One last related complication that arises in this challenge to security is the use of health as a political tool. In Uganda's 2001 elections, for instance, presidential candidates used the stigma attached to being HIV-positive in their mudslinging campaigns, each accusing the other of being infected with the virus. It is not clear if the accusations ultimately influenced voters' choices, but the mere implication of a health crisis influencing electoral choices shows the degree to which policymakers are influenced to exploit a public health issue.
Perhaps the most fundamental threat to security that arises out of a public health emergency is the direct loss of people. This notion has already been discussed here in terms of how a population suffers from losses within its civilian population, but losses of military personnel to disease affect the most traditional concepts of security.
A health crisis within a military community is not a new challenge. In fact, disease has historically accounted for more battlefield hospitalizations than have combat injuries. In the short run, the succumbing of soldiers to disease can result in direct performance inhibition in military missions that range from peacekeeping to defending the homeland by having a fundamental impact on combat readiness.  In the long run, a population that has a difficult time overcoming a public health emergency will be able to produce fewer suitable military recruits and, ultimately, the quality of military leadership will suffer.
There are several broad scope effects that a public health emergency could have on a country's military establishment. When disease is pervasive in both the military and civilian populations in a region, opportunistic invasions by other nations becomes more likely. Additionally, when it is perceived that military personnel are becoming infected with a disease as a result of intermingling with civilians while deployed, the nation that has sent its troops to assist in the situation may become reluctant to continue its mission or to participate in similar efforts in the future, which can have a large impact on peacekeeping, for instance. Finally, military personnel whose immune systems are depressed as they fight an infectious disease can lead to more dire consequences in even a small chemical or biological weapons attack.
Clearly, not all infectious diseases can give rise to public health emergencies. Our analysis of outbreaks that led to public health emergencies, including the Surat plague outbreak and the 2003 SARS outbreak, leads us to conclude that for a disease, or rather the pathogen causing the disease, to become a threat to national security, it must have the following characteristics:
In addition to the foregoing five characteristics, two factors that are highly variable or difficult to measure may be mentioned. First, there is the "dread" factor, which has to do with level of fear engendered by some diseases. Plague is the first disease that comes to mind; people have a visceral fear of this disease because of its history and the many lurid written or filmed accounts where the disease figures prominently. Some diseases may soon acquire a fearful image; this appears to have occurred with SARS. Second, the bioterrorist factor can be important especially for defense planning purposes. Many pathogens that otherwise would not be considered as a security threat because they lack one or more of the characteristics listed above (such as being non-contagious) could be very useful for terrorists. Pathogens identified on the Centers for Disease Control and Prevention's A and B lists of threat agents fit this category.
In this article, we have shown that a public health emergency, whether of natural or laboratory etiology, has the power to challenge many aspects of national security. In the worst possible case, a health crisis can adversely affect a country's economy, its social stability, the legitimacy and authority of its government, as well as the strength and capability of its internal and external defenses. Certainly, the nature of the outbreak, especially its causative pathogen, will determine how it affects the security of a particular nation, and the degree to which each nation is impacted by a particular public health emergency will vary. In particular, infectious diseases that will emerge or reemerge in the future cannot be foreseen, so neither can their possible effects on either global security or those of particular countries. For these reasons, it is safe for us to predict that public health issues will forever be important to governments intent on maintaining national security, even as the very definition of security continues to evolve.
 Security: freedom from danger; measures taken (as by a national government or a governmental unit) to guard against espionage, observation, sabotage, and surprise; Webster's Third New International Dictionary, Unabridged. Merriam-Webster, 2002; https://unabridged.merriam-webster.com.
 Jessica Tuchman Mathews, "Redefining security," Foreign Affairs 68 (Spring 1989), p. 162.
 Public health: the general health of a community and the practice and study of ways to preserve and improve it. Public health includes health education, sanitation, control of diseases, and regulation of pollution; MSN Encarta; https://encarta.msn.com.
 Emergency: [a] sudden crisis requiring action; an unexpected and sudden event that must be dealt with urgently; MSN Encarta; https://encarta.msn.com.
 Jennifer Brower and Peter Chalk, The Global Threat of New and Reemerging Infectious Diseases: Reconciling U.S. National Security and Public Health Policy (Santa Monica, CA: RAND, 2003), p. 8.
 Robert L. Ostergard, Jr., "Politics in the hot zone: AIDS and national security in Africa," Third World Quarterly 23 (April 2002), p. 344.
 National Intelligence Council, National Intelligence Estimate: The Global Infectious Disease Threat and Its Implications for the United States, NIE 99-17D, January 2000, p. 47.
 Brower and Chalk, p. 8.
 David Heymann, "Evolving Infectious Disease Threats to National and Global Security," in Lincoln Chen, Jennifer Leaning, and Vasant Narasimhan, eds., Global Health Challenges for Human Security (Cambridge, MA: Harvard University Press, 2003) p. 110.
 National Intelligence Council, p. 49.
 Ibid., p. 110.
 Brower and Chalk, p. 10.
 Clarence Lam, Crystal Franco, and Ari Schuler, "Billions for Biodefense: Federal Agency Biodefense Funding, FY2006-FY2007," Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science 4 (Issue 2), p. 114.
 Brower and Chalk, p. 8.
 National Intelligence Council, p. 59.
 Ibid., p. 48.
 Ibid., p. 46.
 Ibid., p. 50.
 Ronald Barrett, "Human Ecology and False Allegations: The 1994 Plague in Western India," unpublished work.
 UNAIDS, 2004 Report on the Global HIV/AIDS Epidemic: Executive Summary (Geneva: Joint UN Programme on HIV/AIDS, 2004) in Gary Cecchine and Melinda Moore, Infectious Disease and National Security: Strategic Information Needs (Santa Monica, CA: RAND, 2006), p. 18.
 Gary Cecchine and Melinda Moore, Infectious Disease and National Security: Strategic Information Needs (Santa Monica, CA: RAND, 2006), p. 18.
 United States Government Accountability Office, Global Health: Framework for Infectious Disease Surveillance, GAO/NSIAD-00-205R, July 20, 2000, p. 13.
 Ibid., p. 3.
 Seth G. Jones, Lee H. Hilborne, C. Ross Anthony, Lois M. Davis, Federico Girosi, Cheryl Benard, Rachel M. Swanger, Anita Datar Garten, and Anga Timilsina, Securing Health: Lessons from Nation-Building Missions, (Santa Monica, CA: RAND, 2006) p. xxi.
 Ibid., p. xvii.
 Ibid., p. xxiii.
 Jennifer Brower and Peter Chalk, p. 7.
 Heymann, p. 109.
 Robert L. Ostergard, Jr., 341.
 Heymann, p. 111.
 Ostergard, Jr., 342.
 National Intelligence Council, p. 10.
 Ibid., p. 51.
 Ostergard, Jr., p. 344.
 Ostergard, Jr., p. 342.
 Centers for Disease Control and Prevention, "Bioterrorism Agents/Diseases: By Category"; www.bt.cdc.gov.
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