The Health Dimensions of Human Security

The Health Dimensions of Human Security

FINAL DRAFT Edited November 2015

By Gabriella Arcadu and Nevio Zagaria

The views expressed in this paper are those of the authors and do not necessarily reflect the official policy or position of the World Health Organisation

Nevio Zagaria, MD, Coordinator, Disaster Risk Management for Health Unit, Division of Health Security and Emergencies, World Health Organization Regional Office for the Western Pacific, Manila, Philippines. He worked for international nongovernmental organizations from 1985 to 1996 creating and implementing development and emergency health projects, mainly in Africa. He joined WHO as Emergency Health Coordinator in Angola in 1996 and 1997, then in Geneva as Coordinator of Eradication and Elimination Global Initiatives, and as Coordinator and acting Director of the Health Action in Crisis Cluster between 1998 and 2012, before joining the Regional Office for the Western Pacific in 2012.

Gabriella Arcadu, PhD, is a political scientist with expertise in conflict-affected, transitional and fragile states. She has 20 years of experience in the field, including work in Africa, the Balkans, Central Asia, the Middle East and South-East Asia. Since the late 1990s, she has been involved in the Health as a Bridge for Peace programme of WHO, implementing actions in Egypt, Indonesia and Sri Lanka. In 2005 she assisted in the drafting of the Health and Disarmament, Demobilization and Reintegration section of the Integrated Disarmament, Demobilization and Reintegration Standards later adopted by the United Nations. In 2010 she has drafted a global policy for civil–military coordination in the health sector for WHO, carrying out field research in Afghanistan. She has worked in various capacities for United Nations agencies, nongovernmental organizations and universities developing projects for various donors. Since 2009 she has been Director of 4change, a non-profit association she co-founded that provides training and research activities in conflict-prone and fragile countries.

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Contents

OBJECTIVES OF THE PAPER ............................................................................................................................... 3 KEY POINTS ...................................................................................................................................................... 3 1.

INTRODUCTION ....................................................................................................................................... 3

2.

WHAT IS SECURITY? ................................................................................................................................. 4 Box 1.

3.

Human Security Milestones...................................................................................................................... 5

THE EMERGENCE OF THE CONCEPT OF HUMAN SECURITY ....................................................................... 6 Box 2.

Universal Declaration of Human Rights Article 25 (Part 1) ....................................................................... 6 Table 1. Human security components and related Millennium Development Goals (MDG) or Sustain-able Development Goals (SDGs) .......................................................................................................................................... 7 Box 3. Actions rooted in human security .................................................................................................................... 8

4.

INTERNATIONAL DISCUSSION ON HEALTH SECURITY ............................................................................... 9

5.

HEALTH IN A HUMAN SECURITY FRAMEWORK ...................................................................................... 11 Box 4. Health and Human Security linkages .............................................................................................................. 11 Box 5. Health as the center of the Human Security framework................................................................................ 12 Table 2. Examples of a critical health threat per priority health area........................................................................ 14

6.

POTENTIAL HEALTH CONTRIBUTION TO HUMAN SECURITY ................................................................... 16

7.

CONCLUSIONS........................................................................................................................................ 17

8.

REFERENCES ........................................................................................................................................... 18

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Objectives of the paper This concept paper, The Health Dimensions of Human Security, is intended to contribute to building a common understanding of the origin and evolution of the concept of human security in the health community. The paper presents key terminology related to health and human security in an effort to foster agreement upon a common language. It also highlights the relationships between health and human security, and encourages reflection across the health sector’s humanitarian and disaster risk reduction communities on the potential role that specific health interventions can have in enhancing human security. Finally, the paper outlines key challenges the health sector faces in its role as a contributor to human security.

Key points • The world has become increasingly complex, and so have existing and emerging threats that can challenge human life.

• The traditional state-centric security concept does not provide a useful framework to tackle these challenges.

• States remain the main actors – along with international and regional organizations – for reducing human insecurity, including insecurity related to health threats, but states alone are not sufficient to meet all the challenges.

• The human security concept – notwithstanding the lack of an agreed operational definition – provides a framework that assists in the identification of effective policies to protect and improve the lives of people.

• Health is at the center of human security, and it is directly impacted by food, environmental and economic insecurities, as well as by personal, community and political insecurities; indeed, reaching and maintaining good health requires an acceptable level of security in the other six components of human security – food security, environmental security, economic security, personal security, community security and political security.

• Health priority challenges in a human security framework are those derived from humanitarian crises of both natural and human-induced origin, infectious diseases, and acute as well chronic health inequities and poverty.

• During the last decade, resources for health security actions have been used mainly to build the International Health Regulation (2005) core capacities related to the early detection and response to public health emergencies of international concern (PHEIC), usually infectious diseases. This approach has neglected the other two health security dimensions – humanitarian crisis of both natural and human-induced origin and acute and chronic health inequities and poverty.

1. Introduction The concept of human security emerged in the early 1990s in an attempt to provide a holistic framework that allows understanding of the linkages between security and the various elements that sustain human life. However, more than two decades after the concept was introduced there is no agreement on a definition of human security. In addition, the broad scope of human security has raised doubts about the difficulty of generating operational policies based on the concept. The concept does, however, provide a framework that forces interested parties to look at problems that threaten human survival and dignity in their complexity and interdependence. In this regard, the concept of human security can be a useful tool that will help us avoid the pitfall of developing overly simplistic fixes for complex problems.

The human security framework supports all actors in generating more articulate thinking about 21st century challenges, as well as in fostering the creation of more appropriate operational policies. A human security perspective can help to identify the linkages between health and the other components that sustain human life – placing health within a broader socioeconomic dimension – and stimulating a holistic approach to addressing health problems. Indeed, the components of a human security frame3

work are consistent with the social determinants of health, such as food security, environmental hazards, poor housing, unemployment, poverty and a lack of education.

This concept paper, The Health Dimensions of Human Security, adopts the human security framework as spelled out in its original form in the Human Development Report 1994, published by the United Nations Development Programme (UNDP), which was developed following extensive consultations within the United Nations system and with academics and with civil society.

2. What is security?

Despite the prominence of the issue of security in international debates, the term itself has never been precisely defined, and more surprisingly little effort has been made to do so (Baldwin, 1997). Generally, the term “security” triggers an association with something that compromises safety, particularly as it relates to a set of core values of an individual or a community. What is this “something” that compromises safety? And what core values of an individual or community are being undermined? Attempts to answer these questions produce a wide variance of opinions.

This variance can be traced to three factors: 1. Security for whom? As Buzan has argued, a concept of security that fails to specify a “referent object” makes little sense (Buzan, 2008).

Security is never a neutral concept; it is politically charged. Adopting the nation-state as the main referent object of security puts the interests of the state – and the safeguard of those interests – at the centre of any security policy. On the other hand, thinking and acting within a specified area of interest, for example, an environmental security framework will focus on the protection of the ecosystem, giving priority to policies targeting this purpose.

2. Security from what threats? Which problems, among the many problems that communities, states and the international security system continuously face, amount to be a security threat?

The response to this question has significant operational implications; labeling an issue as a security threat has an enormous potential to raise interest, priority and funding devoted by national and international actors to engage in a specific challenge. In 2000, when the administration of United States President William Jefferson Clinton declared HIV/AIDS a threat to national security, that action immediately triggered a doubling – up to US$ 254 million – of the budget request for funds to be allocated to fight the pandemic (Gellman, 2000).1 3. Security has a subjective component. Security threats for a Congolese can be very different from those of New Yorker, as they are dependent on socioeconomic characteristics of the environment and personal priorities. The same is true for communities and states. This subjectivity includes an element of conscious decision, or as Waever puts it: “The security label does not merely reflect whether a problem is a security problem, it is also a political choice.”

(Wæver, 1993). In other words, what constitutes a security threat can change over time according to a transformation in practical conditions, but it can also change based on variations of interests, perceptions, and will of the main national and international actors – and indeed it has.

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It was the first time that the National Security Council of the United States of America was involved in combating an infectious disease.

The pledge for extra funds eventually resulted in securing 100 million US$ for a newly formed Global HIV/AIDS Initiative and in an increase of 100 million US$ in the 2001 Budget Law compared to the previous year spending ( Budget of the United States of America - Fiscal Year 2001. Page 78 ). In July 2000, also for the first time the United Nations Security Council declared a disease as a threat to peace and security, United Nations Security Council.

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Security of the state In a traditional international relations approach, the term security was – and continues to be –linked to the security of the state, and threats to security are considered attempts or situations that have the potential to undermine the state’s political independence or stability and territorial integrity. In this approach the main tool to respond to a threat is military force. Security of other “referent objects” is, in this view, a consequence of the security of the state. Individuals are secure, if the state they live in is secure, and security in an anarchic international system (a system with no overarching authority) can only be guaranteed by force (war) or cooperation, bilaterally or multilaterally, between individual states. During World War II and throughout the Cold War, this understanding of security dominated strategic thinking and the global security system based on the United Nations Security Council was designed around this paradigm.

Box 1. Human Security Milestones 1945 1992 1994 1999 1999 2000 2001 2003 2004

Statement by the US Secretary of State, Edward R. Stettinius, at the constitutive meeting of the United Nations on 24 June 1945 An Agenda for Peace. Report of the UN Secretary-General Boutros Boutros-Ghali Human Development Report. Report of the United Nations Development Programme Establishment of the UN Trust Fund for Human Security (UNTFHS) Establishment of an informal Human Security Network We the Peoples. Report of UN Secretary-General Kofi Annan to the Millennium Summit Establishment of the Commission on Human Security Human Security Now. Report of the Commission on Human Security Establishment of a Human Security Unit at UN Office for the Coordination of Humanitarian Affairs A More Secured World: Our Shared Responsibility. Report of the Highlevel Panel on Threats, Challenges and Change In Larger Freedom: Towards Development, Security and Human Rights for All. Report of UN Secretary-General Kofi Annan World Summit Outcome Document Establishment of an informal group of Friends of Human Security Thematic debate on human security at the UN General Assembly Human Security. Report of UN Secretary-General Ban Ki-moon Follow-up to General Assembly resolution 64/291 on Human Security Follow-up to General Assembly resolution 66/290 on Human Security Adapted from UNITAR – training material

Emerging threats The state-centric vision of security is still central in the international system. However, in recent decades three factors have emerged that call in question the predominance of this approach vis-á vis emerging threats (Szreter, 2003).

First and foremost was the end of the Cold War. In the wave of instability that fol2004 lowed the implosion of the Union of Soviet Socialist 2005 Republics, war was no longer an affair between nation 2005 states but became mainly a 2005 violent clash among orga2008 nized groups. Scenarios such 2010 as those that played out in 2012 Afghanistan, the Democratic 2013 Republic of Congo and Somalia, and prompted the emergence of the notion of failed states. In many circumstances, states themselves emerged as a major cause of insecurity for their citizens, becoming the primary actors of gross human rights violations.

Second was the process of globalization. Globalization is a centuries-long process, however, the acceleration of movement of populations and goods, and the staggering increase of information and financial flows of the last few decades are unprecedented. This acceleration has increased global interdependence; the problems affecting one state or region impact the whole system.

The third factor was the rise of the awareness of environmental issues and of their complexity. Global warming and environmental degradation became issues discussed by the general public – and governments.2 These factors have generated a number of threats that exceed the capacity of individual states to develop an appropriate response.

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Global warming entered public discourse in 1988; the Kyoto Protocol was adopted in Kyoto, Japan, on 11 December 1997 and entered into force on 16 February 2005.

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Some of these threats have been part of human history throughout the ages, such as infectious diseases, natural disasters and poverty. However, the globalized world has often exacerbated their impact, such as with the accelerated transmission of infectious diseases or the increased intensity of disasters related to hydro-meteorological hazards. Some other threats, given their higher frequencies and characteristics, pose entirely new challenges, such as financial crises,3 transnational crime and global terrorism.

In today’s world, where populations, goods and money move more freely than ever before – and with unprecedented speed – prompts reflection on what now constitutes a security threat and what framework can guarantee better understanding of the complexity of the 21st century world, with the ultimate goal of fostering adequate operational policies.

3. The emergence of the concept of human security The concept of human security, which emerged in the post-Cold War period, acknowledged the increased interdependence of individuals and nations that has resulted from globalization. The concept of human security, in its present form, was first articulated in the Human Development Report 1994 (UNDP, 1994), based on the work of economist Mahbub Ul Haq (Ul Haq, 1994). The report shifted the focus of security from one of security of state to one of the security of people. The threats taken into consideration may not challenge the state as an entity, but may threaten the lives of its citizens.

Box 2. Universal Declaration of Human Rights Article 25 (Part 1) Everyone has a right to a standard of living adequate for the health and well-being of himself and his family, including food, clothing, housing, medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.

The state is still considered a main actor, along with international organizations, nongovernmental organizations and civil society at large, for the implementation of policies toward the achievement of human security.

The report defines human security as “first, safety from such chronic threats as hunger, disease and repression. And second, it means protection from sudden and hurtful disruptions in the patterns of daily life – whether in homes, in jobs or in communities” (UNDP, 1994).

Freedom from want and freedom from fear are the two pillars that sustain the whole concept of human security; pillars enshrined in the Universal Declaration of Human Rights, especially in Article 25 (Box 2). These same principles have been embedded in the embryonic Asian human rights system.4 Human security is built around four principles: 1. Universality: it pertains to all human beings in all places.

2. Interdependency: consequences of human insecurity in one place easily travel the world and affect other nations.

3. Early prevention: it is easier and more economical to achieve and maintain human security through early action addressing the roots of insecurity, rather than through response to the consequences of insecurity.

4. Centrality of the people: it is concerned with how people live in their society, their freedom to exercise choice, their access to socioeconomic entitlements, and whether they live in war or peace (UNDP, 1994).

The framework of human security is articulated in seven components: 1) economic security; 2) food security; 3) health security; 4) environmental security; 5) personal security; 6) community security; 3

In the wake of the 1997 Asian financial crisis, the nominal gross domestic product (GDP) among member states of the Association of Southeast Asian Nations (ASEAN) fell by US$ 218.2 billion (31.7%) in 1998. In the Republic of Korea, the US$ 170.9 billion fall in 1998 was equal to 33.1% of the 1997 GDP. Millions of people fell below the poverty line in 1997–1998. Indonesia, the Republic of Korea and Thailand were the countries most affected.

4 E.g. ASIAN HUMAN RIGHTS COMMISSION 1998. Asian Human Rights Charter: A Peoples' Charter, Declared in Kwangju, South Korea, on 17 May 1998, Asian Human Rights Commission. Par. 7.1 and ASEAN 2012. Human Rights Declaration. Art. 28 and 29.

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Table 1. Human security components and related Millennium Development Goals (MDG) or Sustainable Development Goals (SDGs)5 Economic security

Food security6

Health security7

Environmental security Personal security

Community security

Political security

Threats deriving from poverty. (MDG 1 Eradicate extreme poverty and hunger. SDG-1 End poverty in all its forms.

MDG 2 Achieve universal primary education. SDG 4 Ensure equitable quality education ) Requires for its attainment a basic income either from productive work or from a government social safety net; the prevention and containment of the effects of economic crisis and natural disasters. Homelessness is often the most severe result of economic insecurity, as well of large natural disasters.

Threats deriving from the lack of physical, social and economic access to food (MDG 1, SDG 2 End hunger and achieve food security). For the attainment of this component, food not only needs to be available but people should have the capacity either to produce it or to purchase it.

Linked to access to food are the threats deriving from the lack of food safety, which refers to quality and micronutrient composition of food consumed.

Threats deriving from injuries and diseases (MDG 6 Combat HIV/AIDS, tuberculosis, and other diseases. SDG 3 Ensure healthy lives. SDG 6 Ensure access to water and sanitation). For its attainment, it requires access to health services. The threats to health security are greater for poor people living in rural areas, especially children and women.

Health challenges closely linked to human security include: • health consequences of natural and/or human-induced disasters; • infectious diseases, and events that can generate a Public Health Emergency of International Concern (WHO, 2005); • health consequences of poverty and inequities (MDG 4 Reduce child mortality, and MDG 5 Improve maternal health).

Threats deriving from air and water pollution, environmental degradation and resource depletion, deforestation, natural hazards, and human-induced disasters. (MDG 7 Ensure environmental sustainability. SDG 13 take urgent action to combat climate change. SDG 6, SDG 14 Conserve and sustainable use of marine resources. SDG 15 Protect and promote sustainable use of terrestrial ecosystem.)

Threats deriving from different forms of violence: from the state, from other states, from international terrorism, from other communities/ethnic groups, from one’s self (suicide, substance abuse), or gender-based violence (MDG 3 Promote gender equality and empower women. SDG 5 Achieve gender equality and empower women and girls. SDG 16 Promote peaceful and inclusive society and access to justice.)

These components can be viewed in two ways: • threats to the integrity of cultural diversity (threats to the identity of a community); and • threats deriving from oppressive traditional practices (threats to the individual living in a specific community).

(MDG 3, SDG 5, SDG 16) Threats deriving from political repressions, human rights violations, military dictatorship, state repression and torture. (SDG 16, SDG 10 Reduce inequalities within and among countries.)

and 7) political security (Table 1). These components are interconnected – all are necessary for the achievement of human security, and poor security in one component directly affects the others. For example, food scarcity can impact health security of individuals, or environmental degradation can trigger population movements affecting, among others things, the economic security of a population.

The concept of human security continues to be the subject of an intense debate since it was first introduced in the 1994 UNDP report, and has been critiqued by academics and policy-makers.8 The majority of criticism concerns one main issue: the lack of a clear conceptual definition that leads to a “laundry list of human security issues” (Paris, 2001). As a result there is little guidance in terms of

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This table is based on various sources. Primarily, the 1994 UNDP report and When other sources are used they are specifically mentioned.

The table also refers to the MDGs and the recently adopted SDGs relevant to the specific components.

6 The definition of food security in the UNDP 1994 report did not contain food safety as a threat to food security. However, food safety was inserted as a component of food security in the following years. Among other definitions: “Food Security exists when all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food which meets their dietary needs and food preferences for an active and healthy life. Household food security is the application of this concept to the family level, with individuals within households as the focus of concern.” FAO 2002. The State of Food Insecurity in the World 2001. Rome.

7 The three health areas most relevant for human security were formulated in the Human Security Commission Report and further articulated in CHEN, L. 2004. Health as a human security priority for the 21st century. Paper for human security track III. Helsinki: Helsinki Process.

8 For the debate on human security see the contraposition between two main lines of thought. The first, a broad approach to human security derives directly from the 1994 UNDP report and forms the basis of the UN-appointed Human Security Commission. It is fostered by the Government of Japan (the main donor of the UN Trust Fund on Human Security) and a number of academics. The second is the narrow approach that restricts the parameters of human security to violent threats against the individual or community. It is generally referred to as the “Canadian Approach” and main offspring of this approach was the 2001 report entitled The Responsibility to Protect. ICISS 2001. The responsibility to protect: report of the International Commission on Intervention and State Sovereignty, Idrc.

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prioritizing issues and policy formulation. In fact, there is not a commonly accepted definition of human security, and a number of different definitions have been developed over the years.9 Despite its broad scope and the lack of a clear operational definition, the human security concept – in the relatively short period of time since its formulation in 1994 – has rallied a number of actors behind specific issues with a certain degree of success (see Box 3).

Box 3. Actions rooted in human security - The Informal Network on Human Security, established in 1999, united 13 like-minded states – with Canada’s leadership – and a number of nongovernmental organizations to push forward an ad hoc campaign that led to the approval of the Ottawa ban on anti-personal mines.

- The discussion and the policies around human security lie at the heart of the establishment of the International Criminal Court in July 2002.

- Australia and Canada led the process of rethinking the concept of state sovereignty that resulted in the publication of the influential report on The Responsibility to Protect (2001) that, while adopting a more restrictive approach to human security, pushed forward the principle of the duty of the state to protect its citizens from mass atrocities and the duty of the international community to intervene should the state prove unable or unwilling to act.

- A broad vision of human security is also what inspired the Millennium Development Goals.

Limiting the scope of human security The scope of human security, as outlined in Table 1, is wide and tends to discourage any attempt to prioritize among various potential threats. However, there are few principles – inferred from different definitions of the concept – which can support the effort to identify boundaries to the application of the human security concept.10 First, the definition offered in Human Security Now, a report by the Human Security Commission, invokes the principle of intensity: “protecting people from critical (severe) and pervasive (widespread) threats and situations” (Ogata and Sen, 2003). In other words, a problem should become a human security threat only when its severity in terms of population affected, socioeconomic impact, urgency for action, or potential spillover reach a certain level.

Second, the principle of universality does not mean that human security threats are the same in all places. Threats affecting one region might not affect other parts of the world. For example, risks deriving from geological or hydro-meteorological hazards can have significant variation related to the local susceptibilities and coping capacities. Further, threats can be global in nature or, at the other end, threaten communities at regional, national or subnational levels. Appropriate responses should be geared to tackle the threat at the proper level. This can be summarized as a geographical principle of human security.

Third, as it was outlined earlier in this paper, security threats can change over time. There is therefore a temporal principle pertaining to human security. Some threats continue throughout time, such as global warming; other threats, such as rapid onset natural disasters, can have devastating impacts in terms of human survival but are mostly localized in time and space. Situations change and so do potential and actual threats.

The application of these principles to prioritize policies and actions pose a problem of analysing and measuring “human security levels” in time and across the world. A Human Security Index (HSI) was released in 2008 and updated in 2010 covering 232 countries and territories. The HSI groups indicators into three indices: the Economic Fabric Index, the Environmental Fabric Index and the Social 9

Canada and Japan have been at the forefront in advocating the human security concept and leading the formation of the Human Security Commission in December 2001. Further, Japan has been the major donor in the establishment within the UN Secretariat of the Human Security Trust Fund. For an analysis of all the approaches concerning the concept see TADJBAKHSH, S. & CHENOY, A. 2007. Human security: Concepts and implications, Routledge.

10 A threshold approach to human security was proposed by OWEN, T. 2004. Human security-conflict, critique and consensus: colloquium remarks and a proposal for a threshold-based definition. Security Dialogue, 35, 373-387. In this paper it has been merged with the work of the Human Security Commission that used four criteria to better define health challenges more relevant to human security.

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Fabric Index. Health indicators are included in the Social Fabric Index together with indicators concerning education and information empowerment, diversity, peacefulness, food security, and governance (Hastings, 2011).11 The HIS has not had the impact of the Human Development Index in terms of academic research and policy formulation, but it provides interesting outcomes that can help reshape priorities and identify critical areas within nations.12 Accurate measurement of what constitutes a human security threat remains a challenge. The complexity of the measurement is mainly linked to the multidimensional and dynamic origins of threats. No matter how precise the data is – and socioeconomic data are imperfect – deciding what constitutes a security threat is influenced by the interests and perceptions of the actors who have the power to take action, with it ultimately being a political decision. Further, human security, as it has been described, is more a matter of reaching and maintaining a balance among the various components that sustain human survival and dignity, rather than simply responding to individual acute threats when they arise.

In this sense, human security requires a constant and persistent effort to be protected and enhanced.

Future prospects Despite the lack of an operational definition, the concept of human security triggers reflection on how to reduce the insecurities that affect millions of people around the world. In recent years, following staggering failures in Afghanistan and Iraq, as well as failures of international intervention in crisis areas in general, the concepts of peace-building, post-conflict rehabilitation and military interventions are been reassessed through a human security lens. The argument being that, to tackle conflict in the post-Cold War era, the strategies that have been used were derived from a traditional state-centric vision of international relations (war among nation-states). These new wars take place amid the disintegration of states and involve a profound transformation of social relations during warfare, therefore posing different threats that require different approaches – framed in human security.13

4. International discussion on health security Despite its widespread use, there is still a lack of clarity regarding the scope and meaning of health security. Much like the concept of human security, there is not a generally accepted definition of health security, and the term is circulated among academics and the international community with different, and to a certain extent contradictory, meanings.

In the discussions about health security, three main approaches can be roughly traced (Elbe, 2011): 1. Health security as protection from threats deriving from biological, chemical and radionuclear terrorism. This approach grew directly from the release of sarin gas in Tokyo’s subway system by the Aum Shinrikyo cult in 1995 and letters containing anthrax mailed to prominent addresses in the United States of American soon after 11 September 2001 terrorist attacks. The rising threat of global terrorism and the fear that diseases and other agents could be weaponized for indiscriminate attacks prompted the creation of a number of initiatives and research both in Europe and the United States of America. (The Lancet Infectious Diseases, 2012).

2. Health security as protection from threats posed by naturally emerging and re-emerging infectious diseases. This approach frames infectious diseases in a national security framework concerned with the potential socioeconomic impacts that major outbreaks can have in an increasingly globalized world. Among others, the SARS and avian influenza outbreaks of 2002 and 2003 are examples.

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Health indicators included in the HSI are: Life expectancy at birth percentage; percentage of life expectancy that is unhealthy; percentage of population using improved water source; Health outcome equality.

12 For example the United States of America score of 147th of 232 countries in the composite HIS is mainly due to low performance in some indicators such as the Gini Coefficient of income (in) equality and food security. http://www.humansecurityindex.org.

13 Among others, KALDOR, M. 2013. Human security, John Wiley & Sons. CIVIL SOCIETY NETWORK FOR HUMAN SECURITY 2013. The Human Security Approach in Conflict Prevention and Peacebuilding Position Paper. Input to the United Nations General Assembly Resolutions on Human Security, in particular 66/290 and 66/763 9

3. Health security as a critical component of human security. In this approach health security has a broader meaning targeting, alongside infectious diseases, health threats deriving from poverty, violent conflicts and other humanitarian disasters.

The first two approaches are mirrored in the updated International Health Regulations (IHR), which were approved in 2005 and entered into force in 2007. IHR has been “designed to prevent the international spread of disease” and provide a set of core capacities in surveillance and response covering any “illness or medical condition, irrespective of origin or source that presents or could present significant harm to humans” (WHO, 2005). In other words, the scope of IHR is the international dimension of potential impacts of an outbreak. This approach is usually referred to as global health security, but is also commonly referred to as simply health security. In The World Health Report 2007: A Safer Future (WHO, 2007), WHO adopts this approach giving very little space to health consequences of violent conflicts, large natural disasters, and none to those disasters and emergencies deriving from poverty and health inequities.14 However, even within WHO, there is not a universal consensus about the content of health security.

The Pan American Health Organization, also known as the WHO Region of the Americas, is on the frontline in producing public health policies framed in the human security concept (PAHO, 2010). Also, the WHO European Region embraces health security as a result of the fulfilment of the socioeconomic health determinants (Rockenschaub et al., 2007). In 2009 the WHO Director-General published an article in The Lancet entitled “Primary health care as a route to health security” (Chan, 2009).

The differences among the several approaches to health security are not irreconcilable. They are possibly part of the various dimensions that health professionals have to tackle – at different times, locations and levels of intervention. A few factors must be considered in this regard. The approach put forward by the IHR framework puts some health concerns in a national security context: states fear the impact of acute public health events on their stability and are ready to cooperate to create a response framework – which at the same time prevents or mitigates the international spread of certain conditions or diseases. This approach has been able to give great visibility to a limited number of outbreaks, such as avian influenza and Middle East respiratory syndrome coronavirus, and to rally a significant amount of resources in the international response effort. This view on health security has also raised concerns by some states that health, with attendant security commitments, could pose obligations to individual states without providing benefit to the health of their populations (e.g. does not guarantee access to low-cost vaccines).15 Further, there is a concern within part of the health community that in this framework, some health priorities would be set more by the interests of states than by public health concerns (Feldbaum et al., 2006).

On the other side, health in a human security approach has raised fewer objections within the health community (Elbe, 2011), but has been less able to raise visibility and resources for the health threats affecting large numbers of people. This imbalance between the resources available and the visibility granted to the different health priorities is possibly the greatest gap the international health community faces.

Proposing health security as a stand-alone concept, not entangled with the wider human security framework, masks the relationship between good health and the socioeconomic environment in which individuals, communities and systems operate. Further, this stand-alone approach runs counter to the approach put forward by the analysis of the social determinants of health, which underlines the degree to which health is dependent on a number of conditions related to the physical environment, as well as the distribution of power, money and resources among individuals and communities (WHO, 2011).

14

The thrust of the report was criticized by The Lancet as a “missed opportunity”. THE LANCET 2007. WHO fails to address health security.

The Lancet, 370, 714.

15 An example is the heated discussion that occurred during a WHO Intergovernmental Meeting (IGM) on Pandemic Influenza Preparedness: Sharing of Influenza Viruses and Access to Vaccines and Other Benefits. The meeting was organized to resolve the crisis after Indonesia refused to share virus isolates from human cases of H5N1 influenza. Indonesia voiced its concern that in this system the country was unlikely to receive any benefits, including vaccines or technology transfer. Portugal, then holding the presidency of the European Union, attempted to introduce the term “global health security” into a draft statement. Portugal stated that global health security should prevail over other laws. This was vigorously opposed by Brazil, India, Indonesia and Thailand, with Brazil stating that it was not committed to working under the security concept. SHASHIKANT. 2007. WHO meeting on avian flu virus ends with draft documents. [Online]. http://www.twnside.org.sg/title2/health.info/twnhealthinfo041107.htm.

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The risks of a stand-alone approach to health threats have been highlighted by the Ebola virus disease outbreak in West Africa, where the initial local and international responses triggered by IHR proved to be late and inadequate, not only to counter the outbreak within the countries involved, but also to manage the international dimension of the event – the primary purpose of IHR. The recognition of the Ebola outbreak as a threat to peace and security was only highlighted in September 2014 in a United Nations Security Council Resolution, more than six months after the beginning of the epidemic and its spread in three countries.

The legitimate objective of fighting the potential international consequences of an epidemic cannot overshadow the fact that the majority of people, especially in low-income countries, become ill and die because of endemic diseases such as malaria, tuberculosis and HIV/AIDS, or as a consequence of weak public health systems (e.g. maternal mortality). Strengthening health systems and fighting socioeconomic inequities in low-income and fragile states has to be given a higher priority in the health and human security agenda. Only functioning and reliable health systems operating in an equitable environment – an environment where individuals and communities have socioeconomic entitlement – can create a framework capable of capturing the complexity of health threats in their different dimensions and devising policies able to respond to this complexity. Ultimately, only in a similar framework will tools, such as IHR, provide a “front line” of services strong enough to withhold the impact of explosive outbreaks, countering their spread locally and internationally.

5. Health in a human security framework The centrality of health for the attainment of human security is well delineated in the Human Security Commission report. Human Security Now: “Health security is at the vital core of human security – and illness, disability and avoidable death are ‘critical pervasive threats’ to human security.” (Ogata and Sen, 2003). Box 4 clearly outlines how health threats can strike the core of the human security triangle, affecting the survival, dignity, and livelihoods of people.

Box 4. Health and Human Security linkages

Source: Human Security Now, p. 97

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Box 5. Health as the center of the Human Security framework Community Security

Environmental Security

Political Security Health Security

Food Security

Economic Security

Personal Security

The report adopts the WHO definition of health: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” In this sense, good health is at the centre of the individual capacity to be economically productive, socially engaged and ultimately in charge of the choices regarding one’s life. Lastly, health does not only pertain to the individual but it also has a public dimension. As Ogata and Sen point out: “Good health is a precondition for social stability. Sudden outbreaks of a contagious disease or other health crisis can destabilize an entire society.” (Ogata and Sen, 2003). The health–human security nexus works also in the other direction: good health does not depend only on the efficacy of health systems and policies, but it is also dependent on actions tackling the social determinants of health, such as “eradicating hunger and poverty; ensuring food and nutritional security; access to safe drinking water and sanitation; employment, decent work, and social protection; protecting environments and delivering equitable economic growth”, and of course, ensuring the security of individuals (Rio Political Declaration, 2011).

While placing health at the centre of the human security framework may well force the concept, it also ignites a much- needed discussion about the linkages health has with the other components. Indeed, there is no doubt that among the seven human security components, health is probably the most dependent on the others. Box 5 visualizes this centrality.

Positioning health in a human security framework Not all health problems that affect populations and individuals can be considered human security threats. In essence, there are four criteria that can help identify health problems related to human security, as well as three priority health areas related to human security.

Four criteria Four criteria can help identify health problems that are more relevant to the attainment of human security:16 1. Scale – health threats affecting large numbers of people in the present and potentially in the future.

16 The definition of the four criteria has been adapted based on the approach of the Human Security Commission Report and the further articulation of the concept contained in: CHEN, L. 2004. Health as a human security priority for the 21st century. Paper for human security track III. Helsinki: Helsinki Process.

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2. Urgency – health threats that require immediate attention for they pose significant risks to survival or to the future well-being of the individuals affected (e.g. health problems created by emergencies or crises).

3. Intensity – health threats that can have a significant social and economic impact.

4. Externalities – health threats that can have a significant spillover effect beyond the location or communities where they emerge.

Three priority health areas Applying these four criteria, three priority health areas stand out as relevant for human security: 1. Health threats emerging from violent conflicts and other humanitarian crises related to natural hazards.

2. Infectious diseases.

3. Health threats emerging from extreme poverty and health inequities.

Continuing high rates of child, neonatal and maternal mortality in some countries are among the most common examples of health inequities contributing to a lack of human security. Where these vulnerable groups do not have access to effective health interventions that ensure the reduction of avoidable morbidity and mortality, most often other components simultaneously affect their overall human security. Access to basic health services by the most disadvantaged in these societies is a fundamental step toward universal health coverage, and at the same time a milestone in building health systems that are resilient to disasters.

International response to priority health areas relevant to human security Frameworks are in place that trigger some form of response from the international system for the first two priority health areas mentioned above, namely: 1) health emerging from violent conflicts and other humanitarian crises related to natural hazards; and 2) infectious diseases.

Natural and human-induced humanitarian crisis: Major humanitarian emergencies – the so-called Level 3 crisis 17 derived from conflicts or natural disasters – trigger a Humanitarian System-Wide Emergency Activation where exceptional measures, in terms of mobilization of human and financial resources, are taken to respond to the emergency. The assessment of the situation is carried out according to five criteria: 1) scale; 2) urgency; 3) complexity, i.e. multi-layered emergency; 4) capacity, i.e. low national response capacity, weak/fragile state; and 5) reputational risk, i.e. media and public attention and visibility (IASC, 2012).

As can be seen, there are several similarities with the criteria proposed to identify the health priorities relevant to human security. Ongoing emergencies where the system-wide response has been activated as level three humanitarian crises, following the new approach produced by the Transformative Agenda of the Inter-Agency Standing Committee, include Iraq, Syria, Typhoon Haiyan in the Philippines, the Central African Republic, Ebola in West Africa, and South Sudan.

Infectious diseases: If an outbreak of a well-known infectious disease, a new emerging disease or a re-emerging disease has the potential of becoming a public health emergency of international concern (PHEIC) it triggers IHR procedures, including the obligation of Member States to inform WHO by “the most efficient means of communication available and within 24 hours of assessment of public health information” (WHO, 2005). A committee of experts is then convened to advise the WHO Director-General on the recommended measures to tackle the situation. These recommendations include “health measures to be implemented by the State Party experiencing the PHEIC, or by other States Parties, to prevent or reduce the international spread of disease and avoid unnecessary interference with international traffic”.18 An example of international mobilization within this framework is the re17

There are three grades defining emergencies and the scale of the international response. Grade 1: a single- or multiple-country event with minimal public health consequences; Grade 2: a single- or multiple-country event with moderate public health consequences that requires a moderate WCO response and/or moderate international response. Grade 3: a single- or multiple-country event with substantial public health consequences that requires a substantial international response. Taken from WHO 2013. Emergency response framework (ERF).

18 IHR procedures concerning public health emergencies of international concern (PHEIC). http://www.who.int/ihr/procedures/pheic/en/ 13

sponse to avian influenza (H7N9) triggered by the emergence of a few cases in China in March 2013.

On 8 August 2014, the WHO Director-General declared the Ebola outbreak in West Africa a PHEIC. Poverty and health inequities: It is this third health priority area in which the international response mechanisms are weakest. There is a wide consensus that poverty increases the vulnerability of communities, exacerbating health consequences of disasters and emergencies.19 Two of the main health problems related to poverty – maternal morbidity and mortality and under-5 child morbidity and mortality – relate to specific Millennium Development Goals. Still, no set of procedures is in place to respond to poverty-induced health threats.

Table 2 illustrates three examples of critical health threats for the health priority areas identified above.

Each threat has been rated on a scale from 1 to 5 (+ to +++++) against the five criteria adopted to identify health problems relevant to human security. The minimum on the Scale, Urgency, Intensity or Externalities is represented by 1, and 5 represents the maximum. The scale has been applied rather arbitrarily and requires further specification. It is here used to provide a tool to compare different health threats against the set of aforementioned criteria.

Table 2. Examples of a critical health threat per priority health area Priority health areas relevant to human security

WHO Western Pacific Region 2013

Scale

Urgency

Intensity

Externalities

/impact

Selected examples Natural and/or humaninduced humanitarian crisis Infectious diseases and other events that generate PHEIC

Typhoon Haiyan Level 3

+++++

+++++

+++++

++

+

+++

++

++++

Humanitarian System-Wide Emergency Activation

Avian Influenza H7N9

Level 2

Extreme poverty and health inequities:

High neonatal and maternal mortality

+++

+++

++

++

• Avoidable neonatal and maternity deaths • Under 5 infections and malnutrition

Iodine deficiency in the Philippines

++

++

Short term + Longer term20 ++++

+

The three health priority areas noted above – natural and human-induced humanitarian crises, infectious diseases, and poverty and health inequities – require synergistic actions by various sectors. This principle of interdependence is inherent to human security. Extreme poverty can exacerbate health risks derived from a humanitarian crisis, while a humanitarian crisis will impact the livelihoods of populations and the health system’s response capacity, thereby increasing health risks, especially for the most vulnerable. Regarding the principle of interdependency, the Ebola outbreak posed questions concerning the efficacy of the mechanisms for international response to infectious diseases when an acute public health event strikes countries or regions of extreme socioeconomic vulnerability.

19 The link between poverty and vulnerability to disasters is widely documented. The Hyogo Framework for Action 2005-2015 outlined: “There is now international acknowledgement that efforts to reduce disaster risks must be systematically integrated into policies, plans and programmes for sustainable development and poverty reduction”. ISDR UN. Hyogo framework for action 2005-2015: building the resilience of nations and communities to disasters. Extract from the final report of the World Conference on Disaster Reduction (A/CONF. 206/6), 2005. Page 1 par. 4. Further, in 2015 the Sendai Framework for Disaster Risk reduction took the place of the Hyogo framework.

Priority area three is: investing in disaster risk reduction for resilience and among the actions recommended in this area is “to strengthen and broaden international efforts aimed at eradicating hunger and poverty through disaster risk reduction”. UNISDR 2015. Sendai Framework for Disaster Risk Reduction 2015–2030. United Nations Office for Disaster Risk Reduction Geneva, Switzerland. Page 20 par. (h).

20 For the iodine deficiency example, the criteria intensity/impact has been split into short-term and longer-term impact in view of the human security principle of early prevention. The longer-term scale represents the impact the health threat will have in the future, should the actions put into place today fail to respond to the problem.

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The Ebola outbreak has affected already poor and fragile countries, namely Guinea, Liberia and Sierra Leone. National health systems, which were already struggling to cope with the usual high burden of disease, have been completely overwhelmed by the outbreak. The high number of health personnel infected is possibly the indicator that most underlines the weakness of these health systems in terms of trained personnel, protocols for action and the availability of personal protective equipment.21 The international response proved inadequate to contain and counter the spread of the disease. The impact of the outbreak extended far beyond its health consequences, affecting the entire socioeconomic fabric of the countries involved, particularly in Liberia and Sierra Leone. The establishment of the United Nations Mission for Ebola Emergency Response (UNMEER) scaled up the response effort, helping bringing the outbreak under control.22 The health sector has been on the front line of the response to the crisis, and it is possibly better placed than other sectors to drive the thinking that the three priority areas – health threats emerging from violent conflicts and other humanitarian crises related to natural hazards; infectious diseases; and health threats emerging from extreme poverty and health inequities – cannot be tackled separately. They need to be approached in a framework that reduces the vulnerabilities derived from extreme poverty, while responding to the more urgent needs of the population.

21 In Liberia alone, 152 health personnel were infected out of which 79 died. WHO, Ebola situation in Liberia: non-conventional interventions needed. Situation assessment, 8 September 2014. http://www.who.int/mediacentre/news/ebola/8-september-2014/en/.

22 The UNMEER mission was established following Security Council Resolution 2177, 18 September 2014, stating that "the unprecedented extent of the Ebola outbreak in Africa constitutes a threat to international peace and security, and General Assembly resolution 69/1 of 19 September 2014 on measures to contain and combat the recent Ebola outbreak in West Africa. The Mission closed on 13 July 2015.

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6. Potential Health Contribution to Human Security As mentioned previously, the seven components of human security are interconnected, and weaknesses in one component can impact the level of security of the others. On the other hand, action enhancing the level of security in one component can have positive impacts on the others. Table 3 attempts to provide a framework to understand this interconnection, outlining how specific health actions can contribute to the level of security of the other components. The table is by no means comprehensive, and should be considered simply as a tool to stimulate initial reflection on the relationships between health and the other components of human security.

Table 3: Components of Human Security (adapted from the Human Development Report 1994) Health security Areas that generate health threats relevant to human security

Public health actions

Economic security Main components

Conflict, violence and humanitarian emergencies

Basic health services.

Mass casualty management.

Early warning and outbreak response.

Basic service delivery (RH-MISP, MH-PSS*, others ‌) HBP**

Basic income

Infectious diseases and other events that generate Public Health Emergencies of International Concern (PHEIC)

National response - vaccination - preventive measures - curative care - Surveillance International response (global health security) - International Health Regulations

Shelter

Poverty and inequality - Childhood infections and malnutrition - Neonatal and maternal related diseases and deaths

-

-

Quality health services available and accessible at primary and secondary care for the most disadvantaged groups Health care available free/at reasonable costs

Potential health contributions - Public health preventive measures - Free access to health care or at reasonable costs

Food security Main components

Potential health contributions

Physical and economic access to basic food

Food safety (quality and composition in terms of micronutrients of food consumption)

Environmental Security Main components Water scarcity/access to clean water

- technical guidance on diet composition to ensure appropriate nutrition

Potential health contributions - public information on safe storage of water

Land deterioration

Personal security Main compo ponents

Potential health contributions

Main components

Political violence (conflict and war)

-EPI data to map violence and guide policy -HBP -Mental health programmes - Assisting basic health care services Curative and psychological care to victims

Protection of the identity of communities

Criminal violence

Air pollution

Advocacy on health consequences of air pollution

Natural and technological disasters (industrial, transportation)

- preparedness measures to tackle health consequences of disasters - When necessary activate IHR procedures

Community security

Gender based violence

-EPI data to map violence and guide policy - Curative and psychological care to victims

Protection of the individual against traditional discriminatory practices

Potential health contributions

- Public information of health consequences of certain discriminatory practices (e.g. female genital mutilation)

Political security Main compo ponents

Potential health contributions

Human rights protection

- Advocate for the protection of health as a fundamental human right

Political repression

Torture

- Mobilize health community against inhumane and degrading treatment - Curative and psychological care to victims

*Minimum Initial Service Package for Reproductive Health (RH-MISP) and Mental Health and Psychological Support (MHPSS) ** Health as a Bridge for Peace (HBP) is a WHO multidimensional policy and planning framework which supports health workers in delivering health programmes in conflict and post-conflict situations, and at the same time contributes to peace-building. http://www.who.int/hac/techguidance/hbp/en/

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7. Conclusions Despite 20 years of history, a general consensus has yet to be reached regarding definitions and operational priorities of the concept of human security. Even so, the concept of human security creates a framework of analysis that articulates the complex threats we faced in the early years of the third millennium. Compared to more traditional security paradigms its holistic and multi-sectoral approach is better geared to identify priorities for action and comprehensive strategies focused on ameliorating the life of the most disadvantaged.

With its emphasis on “people security” first and “state security” second, the concept of human security helps to focus on the real problems, in particular for the most disadvantaged: Why do people die? Why do they become ill? What threatens their survival on a daily basis? How do hazards of a different nature overlap and interact to generate or contribute to insecurity?

The interdependency among the seven components of the human security framework prompts a note of caution: today’s world is complex and so are the threats it generates. Any strategy devised to counter or respond to these threats must take this complexity into account. Experts in various fields must look towards interdisciplinary efforts, first in the analysis of common and sector-specific problems, and then in the understanding of how and in what way activities in one area impact the others and vice versa.

Health, more than any other of human security framework’s components, is dependent on and influenced by the other components. This interdependency must be at the core of any policy addressing health issues, while a synergistic approach across the seven components becomes a must.

Furthermore, of the three main drivers of health security – health inequities and poverty, infectious disease, and natural and human-induced humanitarian crises – health inequities and poverty should be the basis to build upon and set up the national as well as the overall international support to countries in their response to societal and health challenges. The fight against an epidemic, the set of actions across the disaster risk management cycle and the response to humanitarian crises should be activated from a platform that addresses health inequities. Achieving universal health coverage is the optimal strategy to improve the health dimension of human security and, at the same time, build the capacities to better respond in times of crises to disasters as well as to public health emergencies of international concern.

The following are two critical aspects on which further deliberation is needed: 1. How to manage risks related to each of the three drivers and threats to the three health areas vital to human security, namely: a) Health threats emerging from violent conflicts and other humanitarian crises related to natural hazards; b) Infectious diseases and the related public health emergencies of international concern; and c) Health threats emerging from extreme poverty and health inequities (that lead to specific vulnerabilities, with groups having very poor, if any, access to basic health services).

2. How to develop and adopt effective policies and strategies that address the linkages across the three health security drivers and avoid response that are isolated and lack synergy.

The international community, governments and civil society may consider human security as the framework to mainstream the agendas of sustainable development, disaster risk reduction and climate change adaptation. The health sector must take the lead in promoting this innovative approach.

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8. References __________ 2001. Budget of the United States of America - Fiscal Year 2001.

ASEAN 2012. Human Rights Declaration.

ASIAN HUMAN RIGHTS COMMISSION 1998. Asian Human Rights Charter: A Peoples' Charter, Declared in Kwangju, South Korea, on 17 May 1998, Asian Human Rights Commission.

BALDWIN, D. A. 1997. The concept of security. Review of international studies, 23, 5-26.

BUZAN, B. 2008. People, States & Fear: An agenda for international security studies in the post-cold war era, ECPR Press.

CHAN, M. 2009. Primary health care as a route to health security. The Lancet, 373, 1586-1587.

CHEN, L. 2004. Health as a human security priority for the 21st century. Paper for human security track III. Helsinki: Helsinki Process.

CIVIL SOCIETY NETWORK FOR HUMAN SECURITY 2013. The Human Security Approach in Conflict Prevention and Peacebuilding Position Paper. Input to the United Nations General Assembly Resolutions on Human Security, in particular 66/290 and 66/763 ELBE, S. 2011. Should health professionals play the global health security card? The Lancet, 378, 220221.

FAO 2002. The State of Food Insecurity in the World 2001. Rome.

FELDBAUM, H., PATEL, P., SONDORP, E. & LEE, K. 2006. Global health and national security: the need for critical engagement. Medicine, Conflict and Survival, 22, 192-198.

GELLMAN, B. 2000. AIDS is declered a security threat. Washington Post, 30 April 2000.

HASTINGS, D. A. 2011. The Human Security Index: An update and a new release. Document Report Version, 1.

IASC 2012. Humanitarian System-Wide Emergency Activation: definition and procedures ICISS 2001. The responsibility to protect: report of the International Commission on Intervention and State Sovereignty, Idrc.

ISDR UN. Hyogo framework for action 2005-2015: building the resilience of nations and communities to disasters. Extract from the final report of the World Conference on Disaster Reduction (A/CONF. 206/6), 2005.

KALDOR, M. 2013. Human security, John Wiley & Sons.

OGATA, S. & SEN, A. 2003. Human Security Now. New York: Commission on Human Security.

OWEN, T. 2004. Human security-conflict, critique and consensus: colloquium remarks and a proposal for a threshold-based definition. Security Dialogue, 35, 373-387.

PAHO 2010. Health, Human Security and Well Being. The 50th Directing Council. Washington DC: Resolution PARIS, R. 2001. Human security: Paradigm shift or hot air? International security, 26, 87-102.

RIO POLITICAL DECLARATION 2011. Social Determinants of Health. World Conference on Social Determinantsof Health: Rio de Janeiro, Brazil, 21 October 2011.

ROCKENSCHAUB, G., PUKKILA, J. & PROFILI, M. C. (eds.) 2007. Towards health security. A discussion paper on recent health crises in the WHO European Region: WHO-EURO. SC RES 1308 2000. The Responsibility of the Security Council in the Maintenance of International Peace and Security: HIV/AIDS and International Peace-keeping Operations. 17 July.

SHASHIKANT. 2007. WHO meeting on avian flu virus ends with draft documents. [Online]. http://www.twnside.org.sg/title2/health.info/twnhealthinfo041107.htm.

SZRETER, S. 2003. Health and Human Security in Historical Perspective. In: CHEN, L., LEANING, J. & NARASIMHAN, V. (eds.) Global health challanges for human security. Cambridge, Maasaachssetts: Harvard University Press.

TADJBAKHSH, S. & CHENOY, A. 2007. Human security: Concepts and implications, Routledge.

THE LANCET 2007. WHO fails to address health security. The Lancet, 370, 714.

THE LANCET INFECTIOUS DISEASES 2012. The rise and fall of bioterrorism research. 12, 423.

UL HAQ, M. 1994. New Imperatives of human security. Rajiv Gandhi Institute for Contemporary Studies, Paper N 17.

18

UNDP 1994. Human Development Report. New York: Oxford University Press.

UNISDR 2015. Sendai Framework for Disaster Risk Reduction 2015–2030. United Nations Office for Disaster Risk Reduction Geneva, Switzerland.

WÆVER, O. 1993. Securitization and desecuritization, Centre for Peace and Conflict Research.

WHO 2005. International Health Regulation.

WHO 2007. The world health report 2007: a safer future: global public health security in the 21st century.

WHO. Closing the gap: policy into practice on social determinants of health: discussion paper. World conference on social determinants of health, 2011.

WHO 2013. Emergency response framework (ERF).

WORLD HEALTH ASSEMBLY 2011. Strengthening national health emergency and disaster management capacities and resilience of health systems 64th WHA, Agenda Item 13.4 24 May 2011.

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