EDITORS CORNER

Future Humanitarian Crises Challenges forPractice Policy and Public HealthFrederick M Burkle Jr MD MPH DTM

Senior Fellow 8c Visiting Scientist HarvardHumanitarian Initiative Harvard UniversityCambridge Massachusetts USA SeniorPublic Policy Scholar Woodrow WilsonInternational Center for ScholarsWashington DC USA Section Editor forHumanitarian Affairs Prehospital and Disaster

Medicine

Correspondence

E-mail fburklehsphharvardedu

Keywords disaster future crisis global healthhumanitarian crises public health emergency

Prepared for the Spring 2010 Global Health

Pandemics Poverty and Policy Symposium

DePaul University College of Law Health Law

Institute Chicago Illinois USA

Web publication 03 June 2010

AbstractAfter more than three decades of preoccupation with wars and internal polit-ical conflicts the humanitarian community has the opportunity to re-evaluatewhat humanitarian crises will dominate both policy and practice in the futureIn reality these crises are already active and some are over the tipping point ofrecovery These crises share the common thread of being major public healthemergencies which with a preponderance of excess or indirect mortality andmorbidity dominating the consequences requires new approaches includingunprecedented improvements and alterations in education training researchstrategic planning and policy and treaty agendas Unfortunately politicalsolutions offered up to date are nation-state centric and miss opportunities toprovide what must be global solutions Public health redefined as the infra-structure and systems necessary to allow communities urban settings andnation-states to provide physical and social protections to their populationshas become an essential element of all disciplines from medicine engineeringlaw social sciences and economics Public health which must be recognizedas a strategic and security issue should take precedence over politics at everylevel not be driven by political motives and be globally monitored

Burkle FM Jr Future humanitarian crises Challenges for practice policy andpublic health Prehosp Disaster Aferf201025(3)191-198

The Rise of Public Health EmergenciesPublic health emergencies (PHE) are defined as crises that adversely impactthe public health system and its protective infrastructure that includes watersanitation shelter food and health1 An increasingly common thread ofPHEs have permeated and often dominated the consequences brought on bywars conflicts and large-scale disasters in the last third of the 20th centuryPublic health emergencies occur when the public health protective thresholdis destroyed as it is during war overwhelmed as it was for the citizens of NewOrleans after Hurricane Katrina not recovered or maintained as it was whenShiapublic health infrastructures south of Baghdad were destroyed by the firstPersian Gulf War and purposely ignored by the Saddam regime causing theworst health indices in all of Iraq or denied as they were to select ethnic andreligious groups during the Post-Cold War internal conflicts and persist formany in the decades long smoldering conflicts of Sudan Haiti and Palestine2

In the developed world public health protections are literally invisible topopulations where they are taken for granted The lack of public health pro-tections is what distinguishes many of the have and have not populations ofthe world Wars and large-scale disasters such as earthquakes and hurricanesare defined by the direct deaths and injuries they produce Yet in a very shorttime indirect or preventable deaths from the loss of and failure to recover thepublic health protections can rapidly eclipse the number of direct mortalities

There has been little investment in public health infrastructures in all partsof the world Traditionally public health systems get the short-end of the stickin funding and human resources especially in those departments concernedwith disaster prevention and preparedness Post 911 Federal funding greatlyimproved the capacity of the 2800 local and state health departments in the

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United States to investigate and control pandemics and theconsequences of terrorist events With recent fiscal con-straints both State and Federal funding has declined leav-ing many States with considerable gaps in their ability torespond to PHEs A recent study completed by the Centersfor Disease Control and Prevention found that epidemio-logical capacity critical to outbreak surveillance and con-trol decreased between 2006 and 20093

Public health infrastructures and systems globally havedeclined disappeared or failed to keep pace with thedemands of population growth and density We haveentered the 21st century with deficient dwellings aged andinadequate infrastructure and insufficient capacity torespond to crises especially in ensuring access to safe waterfood sanitation and energy Ecological and environmentalpreservations must be considered as essential public healthprotections Haiti is an example where decades long defor-estation decimated the protective root structure to analarming 14gt5 When a hurricane hits Haiti Cuba andthen Floridathe direct deaths are similar in numberHowever in the absence of normal protective root struc-tures from trees the torrential rains led to massive floodingand mudslides in Haiti resulting in an additional 2500 ormore indirect deaths When a major disaster hits the islandof Hispaniola the impacts are decidedly worse for thedeforested Haiti than the forested Dominican Republic

Indirect mortality and morbidity is considered pre-ventable At first glance all of the future humanitariancrises addressed in this paper may seem distinct but theyhave in common a propensity to result in major PHEs Infact it is a dominant characteristic in all However neitherpolicy nor public health are prepared to address the rootcauses or the consequences of PHEsmdashespecially at thelocal operational or community level

Future CrisesFor the last three decades conventional cross-border inter-nal complex and asymmetrical wars have dominated ourwill and diverted attention away from more subtle andslowly emerging crisesmdashall of which have an even greaterimpact on public health Governments always have beenuncomfortable with public health data Political parties inpower own the public health leadership budgets and theagendas that are deemed important and those that aretabled In the last two decades there has been a deliberateefforts by governments to influence control and interpretpublic health data in a favorable light for political gainsThe scientific community often reticent to enter politicaldisputes has not been stellar in its capacity to interpretpublic health consequences in a manner easily understoodby the citizenry or decision-makers

War and ConflictThere is no reason to expect that wars especially asymmet-rical warring will show a decline The Democratic Republicof the Congo Somalia and the Occupied PalestinianTerritories will remain chronic and smoldering Nigeria hasevery reason to be the next MuslimChristian hotspot TheWestern world at least the United States will remain miredin many asymmetrical conflicts that have no easy solution

certainly no conventional one The internal complex wars ofthe last three decades were post-Cold War battles over ter-ritory and resources Asymmetrical wars such as Iraq andAfghanistan focus on controlling a population bringing allethnic religious and tribal factions into the fray Territoryand resources are a side benefit that is not necessarily animmediate priority of insurgent movements Asymmetricalwarfare has three components that deserve equal attentionthe asymmetrical warfare itself the pervasive insecurity thatimpacts all elements of society especially the civilians andaid community and the emergence over time of an unprece-dented prolonged and catastrophic PHE (Figure I)6

During 2003 Iraq the humanitarian community warnedthe coalition military of the danger of not recognizing theimpact of asymmetrical war on civilians This was severalyears before the troop surge became the soup dejure solu-tion in 2007 to protect and win the hearts and minds ofthe populace In the interim public health indices includ-ing chronic malnutrition infant mortality rates and pre-ventable mortality and morbidity all severely worsened andwhich remain even today Often lost among the attentiongiven to direct violence social ethnic religious disparitiesand inequities poverty injustices cultural incompatibilitiesignorance racism oppression and religious fundamental-ism all will adversely impact the public health and preventor slow its recovery In an early 2010 report nearly 80 ofthe already 300000 conflict-related deaths in Darfur weredue to preventable infectious diseases not violence7 In a2001 Congo study this figure was 908

Post-Conflict Nation-StatesHistory will show that a shameful chapter in humanitarianassistance is the failure of the international community torecover and rehabilitate post-conflict nation-states Thetransition phase from war before sustainable developmentis realized is the most dangerous Social and political sci-entists have shown that the number of victims of pre-ventable mortality and morbidity predictably rise once thewar has been declared over These indirect mortalities usu-ally represent 70 to 90 of all the deaths during the waritself yet markedly increase after the shooting hasstopped9 Those indirect deaths remain high for years anddo not reach the pre-war baseline for a decade or moreWith a declaration of peace tentative or not the humani-tarian community including donors withdraw as fundingand media attention disappears The developed world isquite receptive at responding to emergencies with findingdonors and available humanitarian staff to save livesHowever interest in the hard work of sustainable recoveryand rehabilitation seems to be more risky less receptive andpoorly understood Indeed decision-makers are less clear asto what needs to be done and by whom What is agreedupon is that it takes unprecedented degrees of collabora-tion coordination and communication a level that is notinitially required during the wars humanitarian effort

Whereas deaths from wars have declined the number ofpeople exposed to conflict has increased10 A major mistakeis to assume that once there is some semblance of a decla-ration of peace violent conflict ceases The term post-con-flict is somewhat of a myth It does not necessarily mean

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ASYMMETRICAL WARFARE

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PERVASIVE INSECURITY PROLONGED PUBLICHEALTH EMERGENCY

Burkle copy 2010 Prehospital and Disaster Medicine

Figure 1mdashThree equally critical and integrated character-istics of asymmetrical warfareReproduced from Burkle FM Jr Measuring humanitarian assistance inconflicts Lancet 200819(371)(9608)189-190 with permission fromElsevier

there is peace The difference between populations at warand during the post-conflict phase gets blurred with con-tinued varying levels of conflict intensity Many of the sameviolent events continue but now are termed criminality orbanditry thus speaking to both the urge to affirm thatpeace has finally arrived and a certain degree of collectivedenial For example security level decision-makers may cat-egorize the post-conflict environment through their ownlanguage-lens viewed simply as being permissive non-permissive or semi-permissive Among the confoundingvariables that make current post-conflict environments dif-ferent than the celebrated post-World War II recovery isthe massive proliferation and easy availability of weaponry fac-tors that intimidate the debate toward lasting peace and civility

Unfortunately 47 of countries return to conflict with-in a decade with a rate that is 60 in Africa11 It must beremembered that the post-conflict infrastructure and sys-tem is usually 10 of what it was before the war Predictorsof a return to war include stagnation of economic recoveryand worsening of the infant mortality rate (IMR) a com-posite index which has less to do with the availability ofprenatal antenatal and postnatal care than it has to do withcombined capacities to organize such services through goodgovernance Additionally if the mortality rate remains at thewartime emergency threshold level of 20 deaths10000dayand the fledgling government lacks the public health infra-structure and healthcare resources to adequately manageitmdashinevitably warring will restart

Post-conflict failures are tragic and increasingly add to thelist of fragile states Successful progress requires a coordi-nated mix of military government health education eco-nomic and other resourcesmdashall patiently working togetherfrom an agreed upon strategic plan Humanitarian assistanceshould not cease rather it may need to be escalated for theshort term so that the population can witness an improve-ment of quality health care education and employment Thepost-conflict players must recognize that the transition peri-od remains dangerous for the most vulnerable populations ofwomen children and those with mental health problems

Despite an overall weak track record successes helped bystrategic planning do exist in East Timor Liberia Rwanda

and others Despite the desperation the complex post-conflictenvironment and the basic public health needs has capturedlittle attention among governments donors and practitionersalike The knowledge base is scant Where epidemiologicalstudies proliferated in the war and conflict literature fewstudies of the post-conflict environment are available orfunded if it is not being measured then it does not exist

Biodiversity CrisesBiodiversity systems are areas throughout the world wherethe major life forms that sustain our global biology arefound It is in these areas where the large majority of thecrucial 1500 vascular plant species and at least 70 oforiginal vertebrates reside and define the foundation forsustaining the public health of the planet12 Biodiversityhotspots of which there are 34 are regions with a uniquelyrich level of endemic species that also are most threat-ened13 Understandably dense human habitation tends tooccur near biodiversity hotspots most of which are largeforests or located in the tropics

Tragically 80 of the major conflicts and wars of thelast three decades occurred in 23 of the 34 most biological-ly diverse and threatened places12 Iraq is just one examplewhere only 6 of land is arable packed between and sus-tained by the Tigris and Euphrates rivers The ongoing wardrought and increasing dust storms have severely degradedthe once fertile soil Ambitious plans by Turkey and Syriato divert the rivers from their origins with dams and hydro-electric plants may prove to be the final blow to Iraqs agri-cultural economy Iraqs Minister of the EnvironmentNarmin Othman claimed in January 2010 that environ-mental degradation is being intensified by an acute droughtand water shortage across the country that has seen a 70decrease in the volume of water flowing through the tworivers as they enter the country from the north Othmanemphasized We can no longer in good conscience callourselves the land between the rivers A lot of the water weare getting has first been used by Turkey and Syria forpower generation When it reaches us it is poor qualityThat water which is used for agriculture is often contaminatedWe are in the midst of an unmatched environmental disaster14

Worldwide overpopulation deforestation pollution andglobal warming have produced a negative cumulative effecton these sensitive ecosystems that some studies warn is des-tined for collapse For the United States the south-costalarea of California is the only robust biodiversity system inAmerica and a major contributor to its sustainable foodsupply Other countries biodiversity assets have endowedwar funding most notably in the Congo and Cambodiafrom timber harvesting and the over-production of illicitdrug crops that have dominated and scavenged agriculturallands in Afghanistan South East Asia and LatinAmerica15 Even after the wars the lingering level of fight-ing in many post-conflict environments has stymied therecovery of their once robust biodiversity systemsAdditionally the wide availability of weapons provides easymeans to kill small animals for bush meat severely deplet-ing the remaining vertebrate populations16

The resources focused in these unique biodiversity areasof the world must be recognized as global resources not a

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commodity that can be owned by any one nation-state Thenation-states in which they reside are their protectoratesand have a duty to ensure their lasting viability In the com-ing decades we will hear more of resource wars climatechange threats and eminent domain debates especially indiminishing biodiversity areas as countries sell or lease offland and other resources to the highest bidder

Climate ChangeA recent Editorial in the journal Nature cautioned readersthat climate science like any active field of research hasmajor gaps in understanding Yet the political stakes havegrown so high in this field and the public discourse hasbecome so heated that climate researchers find it hard totalk openly about these gaps suggesting that those whodeny humanitys influence on climate will try to use anyperceived flaw in the evidence to discredit the entire pic-ture So how can researchers honestly describe the uncer-tainty in their work without it being misconstrued17

I share similar anxieties but like most of my colleaguesI believe the evidence clearly shows both natural climatetrends which have shown increasing influence over manydecades along with mans hand in spawning carbon dioxideemissions equally contribute to the predicament we facetoday The undisputed accumulation of carbon emissionsnever will be absorbed or disappear from our environmentThis must be curtailed and hopefully the same science thatdiscovered it can also find a way to eliminate it

The environmental indicators that will remain under heat-ed debate are climate warming biodiversity global cycles ofnitrogen and phosphorus freshwater availability ocean acidifi-cation stratospheric ozone depletion and land-use change ofwhich are inter-related Freshwater availability use is almost atthe tipping point Yemen as one example will run out of allwater in four years Ocean acidification impacts anyone whoresides on or dose to an island nation The challenges are dif-ferent with each island but most serious is general sea level risethe detrimental effects of increased acidification of sea water oncoral reefs and the eventual collapse of the reef ecosystem Overseveral decades millions of islanders will be forced to relocateInterestingly current studies suggest that this migration will beregional migration rather than international mostly driven bydrought soil degradation disappearing islands and loss of foodsecurity It is claimed that Africans will move north toMediterranean countries1820 Polynesians at least in todaysworld will be welcome in New Zealand and Australia Kiribatia Polynesian paradise that straddles the equator will be the firstisland to be totally evacuated President Tong in testimony tothe UN General Assembly emphatically declared that whenpeople migrate they will migrate on merit and with dignityhoping for what he calls a global distribution of the popula-tion The process is already happening with groups numberinga thousand receiving skilled job training as nurses in NewZealand Once work is obtained they will facilitate the contin-ual and orderly exit of others21

Climate changes directly impact the public health Thewater quality and supply on the Polynesian Islands is amajor health issue Rapid urbanization results from relocat-ing costal families where population growth density andthe mounting economic challenges stress the fragile public

health infrastructure Public health risks are being posed bycontaminated and polluted home rainwater storage wellsand lagoons showing elevated bacterial contamination Inlandlocked areas like China severe drought lack of potablewater and super dust stormshave resulted in gt150 millionpeople that authorities openly admit need to be relocatedMainly from water shortages and over irrigation 240 out of291 major springs have dried up22 Africa where it is nowcommon to see dried up river beds has lost many of theirdeeper aquifers With rising temperatures and diminishingrains Lake Victoria has dropped six feet in three years23

Chinas answer is unique in that it has the capacity to buildand populate new cities (such as Shenzhen) that are market-ed as modern economic free zones The major motive howev-er is to provide the public health infrastructure protectionsthat were severely compromised in cities like Shanghai Thisnovel approach has merits but it is not a viable option formost of the worlds megacities suffering similar PHEs

Large-Scale Natural DisastersIt is important to remind readers almost five years afterHurricane Katrina that indirect public health mortality andmorbidity continue to plague New Orleans The breach ofthe levees caused much chaos and exposed large gaps insacrosanct preparedness plans Waters rapidly flooded emer-gency generators in the basements of hospitals ceasing theircapacity to function and forced the permanent closing ofCharity Hospital that once served the indigent populationfor over 250 years Never financed enough to invest in anelectronic surveillance system all the New OrleansDepartment of Health warehoused paper turned to pulpThe public health system and much of its infrastructurecame to a halt With presses out of commission a small staffof the Times Picayune a New Orleans newspaper iconremained behind to post electronic stories24 Over the ensu-ing months their readers alarmed at what appeared to be anunexpected increase in published obituaries contacted thebarebones remnants of the Public Health Departmentwhich launched a study that confirmed a 47 increase inmortality one year post-Katrina The excess deaths attribut-able to loss of a number of social and physical protectionsalmost five years later slowly are being recoveredImmediately there were 38 fewer hospital and 56 fewerpsychiatric beds Despite post-Katrina increaess in suicidesand mental health problems psychiatric services continuedto suffer with the last inpatient psychiatric bed closing inNew Orleans in September 2009 Although funding wasrequested as of 2010 a non-paper surveillance system forNew Orleans was not budgeted Experts estimate that it willtake 20-25 years to rebuild the city at the current pace26

The Indian Ocean Tsunami has had a similar historyDespite what arguably is the most robust voluntary dona-tion program ever almost six years after the Indian OceanTsunami large gaps in shelter sanitation potable waterhealth facilities and workers have been reported in coun-tries affected by the disaster27

Globalization ampf UrbanizationBeing a constructive critic of the economically driven defi-nition of globalization that has dominated our thinking

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over the last 15 years I have concerns over its impact onpublic health During the 1950s studies showed severehealth indices especially among women and children in thedeveloping world This prompted the world health leader-ship to gather in Alma-Ata in central Asia with plans toprovide by the year 2000 equity of health worldwide TheAlma-Ata Declaration assumed that health and educationwere human rights28 Although major progress was madethe initiative eventually stagnated under political pressuresand major internal conflicts especially in Africa25 In con-trast globalization dominated by World Bank initiativestook hold in promoting outsourcing opportunities newindustries and the development of megacity resources thatpromised employment to many of the worlds poor Manycities grew at the rate of one million people every sixmonths The mantra of the World Bank initiativesimprove the economy and everything else will followincluded health not as a right but a responsibility thatthose benefiting from a strong economy would buy Manyareas under World Bank development historically depend-ed on public healthcare hospitals and other facilities forcare During financial growth some were maintained fromthe coffers of the developing industries but in reality anoverall net reduction in expenditures for public healthhealth education and development occurred Among theemployed and unemployed a widening gap occurredbetween the new have and have not populations Healthinequities of the 1950s Alma-Ata era returned and wors-ened among the poor Urban leadership faced with thesedisparities admits that health for many has become amajor security issue30

Urbanzation^r^ is not problematic when public healthinfrastructure precedes population expansion where out-side sources can provide essentials such as food and whenthe urban economy remains an economic advantage to thecountry On the other hand rapid urbanization is anunsustainable process The public health infrastructure can-not keep up and often collapses and the failing economydrains the nation-state Mumbai the most densely populat-ed city worldwide has gt30000 peoplekm2 and in someareas this exceeds one millionkm2 And yet gtl600 newfamilies move into Mumbai every day

Rapid urbanization has produced an invisible popula-tion with unknown demographics or knowledge of theiraccess to basic health With little or no representation bythe humanitarian community no one could guarantee basicsocial and physical protections This situation worsenedwith the financial crisis one example being China whereauthorities admit to gt26 million newly unemployed Mostof the young adult unemployed males who sent moneyhome to support their rural families are unable to returnhome where the local communities fear they will take thefew available jobs away Authorities admit to increasingcriminality and mass incidents31

The rural poor as they did during the 1850s IndustrialRevolution flock to urban centers A poverty-ridden familyearning S2day will gladly welcome S4day despite remain-ing locked in extreme poverty In the developed world 4mdash6of the populations are urban squatters whereas up to 70are in the developing world3233 Currently 59 million new

urban dwellers are added annually worldwide 89 in devel-oping countries34 Megacities like Mumbai reveal blatantevidence of the contradictions of globalization where mul-tiple modern buildings front miles of decrepit shanty towns

Goldstone in quoting bom The Economist and UN data sug-gests that most of the worlds expected population growthwill increasingly be concentrated in todays poorest youngestand most heavily Muslim countries which have a dangerouslack of quality education capital and employment opportuni-ties and for the first time in history most of the worlds popu-lation will become urbanized with the largest urban centersbeing in the worlds poorest countries where policing sanita-tion and health care are often scarce35 Projections of the UNforecasts (Figure 2) might even understate the reality becausethey reflect the medium growthrates36

New occupants tend to move to resource poor and dis-aster prone areas (ie earthquake flooding) of the citieswhere sanitation is ignored and infectious diseases moreprevalent Currently urban settings have the highest world-wide lt5 years of age and IMR Dense growth worseninghealth indices poverty and social tensions are a recipe forincreasing disruptive tensions

A megacity usually is defined as a metropolitan area witha population in excess of 10 million37 Port-au-PrinceHaiti with a severely dense population of three million didnot fit this definition yet shared the same problems ofabject poverty It is the density of populations not the totalnumber which are the major driver influencing diseasepoor sanitation shelter unsafe water and food quality anddistribution If geographic density of populations was usedmany more urban settings would be among the growing listof those at great risk Today there are over one billion peo-ple without basic food for health meaning that while theyobtain some food it is not of the quantity or quality (lackof essential micronutrients) to ward off disease Internationalfood programs only feed about 10 of this population

Epidemics and PandemicsThere have been gt70 new or re-emerging diseases duringthis past decade For viruses and other microorganisms thatdepend on human transmission to survive it is a wonderfultime to propagate Dense populations and uninhibited airtravel are fertile soil for transmission from one human hostto another Severe acute respiratory syndrome (SARS) wasthe name given to the coronavirus a relative of the commoncold which began in Guangdong Province China andspread to 37 countries in 10 days Guangdong Province oneof the most densely populated areas of the world is highlyvulnerable to the emergence and re-emergence of commonand rare viral pathogens But it is not just about viruses InJanuary 2010 one of the smallest yet dense island nationsthe Marshalls was declared a public health emergencyThis happened following an outbreak of drug-resistanttuberculosis (TB) a large mycobacterium when governmentauthorities considered calling upon special powers of quaran-tine for people who were not complying with TB preventionrequirements38 Little known is that between 1969 andtoday bubonic plague cases which number only 10-15 peryear have spread from northern New Mexico to all stateswest of the Mississippi3 The difference between these cases

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Billionsn

World total

1750 1800 1850 1900 1950 2000 2050 2100

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Figure 2mdashPopulation growth 1750-2100 The globalpopulation doubled between 1950 and 1987 from 25 bil-lion to 5 billion Reaching the first 25 billion took thehuman species from its beginnings up to 1950 the second25 billion took less than 40 years Reproduced from MerrickTW et ah World Population in Transition Population Bulletin198641(2)44-45

and those in Africa and India for example is the capacity ofpublic health surveillance and management systems in theUnited States to deal with these threats on a daily basis

Both SARS and the recent H1N1 can be seen as dryruns for what eventually is predicted to be a pandemic of amore lethal viral pathogen Viruses mutate incessantly inorder to remain viable pathogens Avian influenza which todate has not mutated in the one genomic area that wouldensure easy human to human spread has a mortality ratebetween 40-60 The poorer the country the higher themortality rate Surveillance systems that are critical to thediscovery investigation and control of infectious diseaseshave markedly improved in the developed world out of fearto protect their populations and economies These systemsthough remain inadequate in developing countries wherethe emergence and spread of pathogens is most likely

The SARS experience prompted a modernization of theInternational Health Regulations (IHR) which legally bindscountries to work together to prevent protect and control thespread of infectious disease With SARS the IHR became aTreaty in 2007 and to date has proven to be a successfulmodel for global cooperation to protect the public health4041

However even with impressive advances in the science ofpandemics and in strategic and tactical preparedness localcommunity operational level plans and capacity remain defi-cient Western models of care are individual and hospital-cen-tric Epidemics and pandemics are by definition PHEs thatdemand a population-based approach requiring unprecedent-ed coordination and cooperation between the clinical work-force and public health authorities Operational requirementsfor communities call for robust tele-healthline systems surgeallocation of scarce resources system-wide integrated triage-management citizen-supported self or self-assisted care andalternative health facilities to name but a few

Emergencies of ScarcityAlex Evans a Fellow at the Center on InternationalCooperation at New York University has been at the fore-front of alerting society about the need to see energy food

climate and water security as different facets of the sameunderlying issue of resource scarcity rather than as separateissues that happen to share a few attributes The driver ofthese emergencies is the increasing worldwide demandenergy rise of 45 and food 50 by 2030 and water 25by 2025 He cautions that the pattern of trying to manageone scarcity at a time without taking the others into con-sideration creates a major risk of unintended conse-quences42 Distributional conflicts are already emergingResource wars called complex internal wars that beganamong emerging post-Cold War countries in the 1990swere the first hint of problems to come

These emergencies are inextricably linked to biodiversi-ty hotspots climate threats and the scarcity of remainingforests and arable lands most of which lie in the least devel-oped countries Import dependent countries such as ChinaJapan South Korea and many in the Middle East claim theright to purchase farmland in foreign countries to meetnational food security needs at home For almost two yearsSouth Korea negotiated a no-cost 100-year lease of half ofall arable land in Madagascar a country suffering severeunemployment and poverty Local farmers had no politicalvoice in the negotiations South Koreas plan was to exclu-sively grow corn for their countries food staple and claimownership of the lands massive water reserves Whendetails of this arrangementreached the populace a politicalcoup abruptly ended the contract The South Korean gov-ernment response We want to plant corn there to ensureour food security Food can be a weapon in this worldreveals much to worry about43 Curiously the fact that thisevent did not make even a ripple in the worlds press or psy-che is equally alarming Similar purchases of energy fromAfrica and the Artie South China and Caspian Seas byindividual countries now are commonplace

For many decades the public health of a country wasrevealed by disasters that kept governments honest byimmediately defining the public health and exposing itsvulnerabilities44 Not surprisingly governments in powerwere either replaced post-disaster by election or by coupHurricane Katrina and the Haiti earthquake proved thecapstone events that exposed the state of public health pro-tections not that they were very well hidden Scarcity ofenergy water and food already defines the public health inmany countries but in the near future these capacities will bethe indices to measure the public health country by country

Evans suggests key agendas to build resilience to scarci-ty among poor people and fragile states42

1 Improve surveillance and early warning and cites theG20 Global Impact and Vulnerability Alert Systemof April 2009 that integrates data about conflict riskhuman vulnerability and political economy dynamics

2 Mitigate unsustainable population growth Anyreduction requires the empowerment of women astatus not acceptable in most countries that havedense populations

3 Focus on and support agriculture especially smallfarms with technological know-how and micro-cred-it programs

4 Initiate social protection systems and safety nets toreduce vulnerability

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5 International effort to scale-up capacity of naturalresource governance

6 Connect conflict prevention resolution with naturalresource scarcity in mediation and prevention

7 Upgrade emergency capacity to deal with scarcity crises

Impact on Policy and Public HealthThe way in which we perceived and defined public healthbegan to change several decades ago Environmental andpublic health professionals no longer are defined by a nar-row sanitary engineering approach45 Current publichealth reflects governance transportation communicationpublic safety the judiciary and other civil sectors that allowa village town city and nation-state to functionally inte-grate in providing social and physical protections This alsodefines the new public health system and its infrastructureMany of the younger generation already are chest-deep intoglobalization as a planned career New global public healthprograms at the undergraduate level in 137 universities andcolleges have tripled their enrollment in the last threeyears46 Increasingly physicians nurses lawyers engineersand economists just to name a few are seeking a combineddegree with public health For the most part this has beentheir own decision correctly derived from awareness thatpublic health greatly impacts every discipline Global healthconcentrations in schools of public health at the graduateand undergraduate levels are increasingly being launchedand refined Suffering from a post-Sputnik era that favoredmore vertical concentrations in the sciences to win the ColdWar there is realization now that global health studiesrequire a highly integrative approach that is multidiscipli-nary multi-sectoral and supports the multi-ministerial lev-els of decisions that are necessary47 Science and thehumanities must again be equal partners in education

Whereas politically sensitive issues have been restrictedfrom US public education for decades there must be a re-evaluation of this shortsighted decision with global healthtaking center stage from elementary school on Othercountries are not so impeded Academia starting at thegrade school level must be the honest broker for account-ability and transparency between what is being viewed ontelevision and the younger generations quest for knowledge

Humanitarian assistance began to move from rural tourban areas two decades ago as rural wars forced womenand their children to flee to escape rape murder and thetotal absence of social protections Many of us spent theearly decades training the nascent humanitarian communi-ty in building rural refugee camps wells pit latrines defe-cation fields and learning basic field epidemiology Nowmany of these same women find themselves trapped inurban settings with few social protections and scant oppor-tunities for work except prostitution The state of health forwomen and children is worse now than when I began myhumanitarian career gt45 years ago Those who definethemselves as humanitarian professionals have doubledfrom a decade ago to almost 200000 today They are eagerand well traveled But like us all they do not know whatthey dont know Much of the education and trainingremains outdated The humanitarian community policywonks and the military have entered the 21 s t century

unprepared to protect the urban public health or handleemergencies of scarcity

When it comes to emergencies of scarcity no develop-ing or developed country alike should be excluded in meet-ing Evans key agendas Land grabbing and the failure of aconcerted cry of foul by the rest of the world defines thepower and influence that rich countries believe they areentitled to If it was not for media attention theMadagascar case would not be known Land grabbing willcontinue to severely impact poor people and fragile stateswhich lack the social protections and political and institu-tional means to resolve access to resources What is mosttroublesome is that power brokers do not see this as a majorproblem but as a right of countries with means to protectthemselves The answer to our future crises must be a globalsolution not one dictated by any one individual nation-state

We know that the world has the food to feed the exist-ing population yet gt1 billion starve Can the global com-munity make what works for the IHR treaty and infectiousdisease control for water food energy and climate threatsThe global community currently has only two very restric-tive choices in managing climate threats One mitigationdefines the legal and diplomatic efforts of the G20 negoti-ations that call for reduction in population growth ratesensuring broad social protections and decreasing carbonemissions So far they have failed The second choice is forpopulations impacted directly by these threats to identifytheir own vulnerabilities reduce them through their ownmeans and learn how to adapt defined as the newresilience In Polynesia if adaptation does not work thengovernments must have strong migration policies in placeto emigrate their populations 1

The question that will be hotly debated at every levelover the next decade is what responsibilities apply inhuman relationships on a global or transnational levelWill global justice mature enough to demand of the glob-al community remediation of past injustices the establish-ment of fair terms of cooperation between nations andwillingness to address the basic facts of poverty48 As inHaiti today will the collective charity still be based onfeeling sorry or strive to understand and reverse the polit-ical and economic institutional causes

The global economy will be judged by the capacity ofpublic health infrastructure and systems both within indi-vidual nation-states and the willingness of the global com-munity to be a partner in ownership Shared ownershipwould set priorities fund strategic recovery and rehabilita-tion and support micro-and macro- financing that givespriority to public health protections both physical andsocial If given the political responsibility the younger gen-eration will in the next two decades redefine globalizationnot from economics alone but from a foundation of healtheducation and human rights Arguably this will only berealized if water energy food health sanitation and shelterare universally protected In 2002 world governmentsagreed to significantly slow the rate of biodiversity loss by2010 This initiative has failed In part this is due to the factthat policy-makers at the international level do not haveany single consolidated and robust source of science onbiodiversity and ecosystem services to turn to49 A pro-

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198 Editors Corner

posed Intergovernmental Platform on Biodiversity andEcosystem Services (IPBES) is designed not only toimprove links between science and policy but to investhighly in trainingmdashopening unprecedented opportunitiesfor burgeoning scientists worldwide49

What to propose for rapid urbanization is equally trou-blesome but Paul Romer the growth economist does see asilver lining in Chinas special economic zones He suggeststhat hundreds of these greener and better planned highdensity charter cities might provide millions of desperate-ly poor people their first formal sector jobs lifting them-selves out of poverty faster50 Whatever the solutions theywill be multidisciplinary with a public health core

There is nothing in this prediction that should limitsovereignty or threaten cultures or religions The grandexperiment which the IHR Treaty represents must beanalyzed to see if its principles can do for future crises whatit already has accomplished in controlling infectious diseaseoutbreaks51 Whereas the WHO is the rightful home forthreatening diseases a heavily resourced Office for theCoordination of Humanitarian Affairs (OCHA) under asimilar Treaty could become equally responsible for emer-gencies such as large-scale natural disasters and emergen-

cies of scarcity The OCHA would be expected to have astrong public health presence authority and capacity tomonitor prevent prepare and manage Yet both the IHRtreaty and any movement in the same direction throughOCHA are top-down approaches What the world failsmiserably at is the definitive bottom-up remediation ofthe causes of poverty public health protections and warThe latter requires a rewritten and reformed UN Charterand a Security Council that operationalizes theResponsibility to Protect (R2P)52 initiative which is the besthope forward for legitimating preventive force53 TheWestern world should support a standing task force for theUN an idea first proposed and tabled as Article 43 in the 1945UN Charter

Lastly public health must take precedence over politicsand not be driven by political motives We talk of a populistmovement in the US Important yes but only when thesame issues such as the empowerment of women becomea populist global issue will measurable results occur Publichealth must be seen as a strategic and security issue thatdeserves an international monitoring system somethingthat the G20s Global Impact and Vulnerability Act muststrive to do

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Burkle 199

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DID YOU KNOWPrehospital and Disaster Medicine haspublished more manuscripts about massgatherings than any other journal

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