Medicine, Conflict and Survival Health in Fragile States: Opinion Piece Mahiben Maruthappua, Brooke Bentonb , Katharine Harrisc , Preeti Patelc, Brian Godmand,e and Alexander E Finlaysona* a Green Templeton College, University of Oxford, UK Tulane University, New Orleans, Louisiana, U.S.A c King’s Centre for Global Health, London, UK d Division of Clinical Pharmacology, Karolinska Institute, Stockholm, Sweden e National Institute for Science and Technology on Innovation on Neglected Diseases, Centre for Technological Development in Health, Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, Brazil b (Received XX; Accepted XX) State fragility remains one of the most significant challenges to the well-being of those living within conflict-affected, insecure settings Civilian populations affected by armed-conflict are more likely to suffer ill health and die prematurely In light of evidence suggesting fragile states are furthest away from achieving the 2015 Millennium Development Goals, this paper aims to discuss the relationship between the security of a State and the health of its people, as well as in turn, the possible means to address the high burden of ill health in fragile states Haiti is also explored as a case-study This study serves as a platform for the discussion of improving health and long-term sustainability in conflict-affected states _ *Corresponding author Email: alexanderfinlayson@gmail.com M Maruthappu et al Key Words: fragile states; security; global health; Haiti; WHO health system building blocks Introduction The relationship between the security of a State and the health of its people is complex and multifaceted Fragile states present unique challenges to healthcare systems, whether through increased burden of disease, conflict, scarcity of healthcare workforce, financial limitations, fragile governance or weak institutional leadership (Haar and Rubenstein 2012, 289-316; Newbrander, Waldman and Shepherd-Banigan 2011, 639-60; Sondorp and Patel 2004, 4-5; Horton 2001, 1472-73) For example, rapid, uncontrolled population movements appreciably increase morbidity and mortality (Toole and Waldman 1997, 283-312; Salama et al 2004, 1801-13) This is illustrated by the fact that during outbreaks of cholera, mortality increases more than 50-fold among displaced populations versus situations where conditions are stable (Goma Epidemiology Group 1995, 339-44) In addition, population displacement following disasters can severely complicate care provision, further adding to the burden of disease (Bengtsson et al 2011) There are also compelling arguments why a reciprocal dependence also exists, such that strengthening health systems to improve human health can, in turn, contribute to improvements in human security and equity (Bornernisza et al 2010, 8088; Bisika 2010, 277-81; Lee and McInnes 2003) Finally, according to WHO’s comprehensive definition of health, which includes well-being, there is considerable semantic overlap between that which we consider human security and what we consider human health Therefore, while the exact nature of the relationship remains to be elucidated, it is clear that in building capacity in fragile states, health and security exhibit considerable interdependence The aim of this paper is to discuss the relationship between the security of a State and the health of its people, as well as in turn, the possible means to address the high burden of ill health in fragile states We explore these issues with a case study of Haiti Fragile states: politics, security and the MDG deficit Fragile states are countries that face particularly grave political, security, development and poverty challenges (OECD 2011) The government in a typical fragile state lacks the capacity or, in some cases, the political will, to provide security, good governance, state services, and economic growth for all its citizens (DFID 2005) Examples of fragile states include Afghanistan, Somalia, Myanmar, Central African Republic and South Sudan An estimated 1.5 billion people live in fragile states and these states are furthest away from achieving the Millennium Development Goals (MDGs) Although some fragile states have shown improvement economically, as a whole they are contributing significantly to the MDG target shortfall In almost every MDG, fragile states are fairing disproportionally worse and as of 2011, not a single fragile state has yet to achieve a single MDG (OECD 2012) Many fragile states are currently or have been conflict-affected leading to even greater instability and breakdown of health service provisions (World Bank and IMF 2007) People living in fragile states are more likely to die early or suffer from chronic illnesses, and less likely to receive a basic education or essential health services Medicine, Conflict and Survival The World Development Report 2011 warns that one of the major obstacles to global development in the 21st century is chronic insecurity caused by cycles of political violence in fragile states (World Bank 2011) State fragility is a political phenomenon Power dynamics, weak governance, corruption, economic crises, failing public institutions, difficult government-donor relationships all contribute to state fragility and insecurity (Chandy 2011; Call 2008, 1491-1507; Stewart 2011) Many fragile states are affected by political violence and armed conflict Different phases of conflict include high-impact humanitarian emergency, chronic lower-impact conflict, and a post-conflict development phase These phases tend to have very different security dynamics Security is usually weakest in countries that suffer from highimpact humanitarian emergency as a result of armed conflict Poor security is a major impediment to providing humanitarian aid in these contexts (Magone, Neuman, and Weissman 2011) For example, in Somalia, the intricacies of clan rivalries, the absence of an effective government, and general insecurity made it very difficult for international agencies to reach the level of humanitarian assistance that was necessary Agencies operating in Somalia, such as Médecins sans Frontières, had to negotiate access with warring parties who can determine whether an aid agency can work in a given area Security tends to improve during the post-conflict development phase Countries such as Rwanda, Mozambique, Ethiopia and Bosnia and Herzegovina which have emerged from long legacies of both political and criminal violence have been among countries making the fastest progress on the MDGs Improved security has been fundamental to achieving impressive development gains in these countries and elsewhere (World Bank 2011) For instance the Republic of Srpska, one of the two entities of Bosnia and Herzegovina accounting for 49% of the land mass, has introduced a number of reforms and initiatives in recent years to improve health care providing direction to other countries (Markovic-Pekovic V, Ranko Škrbić R, Godman B et al 2012) Development progress in fragile states is very much shaped by the presence and engagement of international actors Most conflict-affected fragile states rely heavily upon international aid and humanitarian assistance for basic service provision, as internal state capacities are limited (World Bank and IMF 2007) The way in which international donors engage in fragile states has a crucial role in determining their development progress Challenges such as poor security, weak governance, limited administrative capacity, chronic humanitarian crises, persistent social tensions, violence or the legacy of civil war require responses different from those applied in more stable situations (OECD 2011) There is a need for clearer political guidance and greater transparency around the role of international actors and the political motivations, objectives and impact of their interventions in fragile states The increased international focus on the drivers of fragility we believe requires taking a more context-specific approach to individual fragile situations (OECD 2011) Overall, the way in which donors engage in fragile contexts matters, and which policies and actors they support, subsequently affects state legitimacy, internal security and power dynamics (Chandy 2011; Call 2008, 1491-1507; Stewart 2011) The health system in Fragile States According to the WHO definition “health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (WHO 1948) Healthcare provision can be seen as a social contract between the government and its citizens For fragile states, this means health system strengthening can assist in M Maruthappu et al restoring the government’s legitimacy and therefore contribute to wider state-building (Kruk et al 2010, 89-97) However, strengthening health systems in fragile states is challenging due to a complexity of factors These include high burden of disease, poor governance and leadership, large health inequities (rural vs urban and rich vs poor), scarcity of resources (human, financial, drug supply etc.), and poor information systems (Chandy 2011; Call 2008, 1491-1507; Stewart 2011) Since many fragile states are, or have been, affected by conflict, this may add to the challenge as health and social efforts often suffer from an increased focus on security (Pavignani 2011, 661-79) In addition, conflict impacts the health sector directly as modern conflict is characterised by violence against health workers and medical facilities (Rubenstein and Bittle 2010, 329-40; Coupland 2013, 1075-6) Death and migration of health workers is especially problematic as this leads to critical shortages of those who are to actually administer healthcare Scaling up of human resources for health (HRH) is therefore an important task in health system strengthening This can be done via the following steps: identifying available staff; developing HRH management structures, systems and capacity; clarifying HRH roles and responsibilities; establishing health worker equivalencies and upgrading skills; supporting civil service reconstruction; and widely disseminating HRH information This process of building and retaining a skilled and motivated health workforce is politically sensitive, as it demands effective cooperation between national government, local stakeholders (NGOs, private sector) and donors, as well as shortterm and long-term goals (Smith and Kolehmainen- Aitken 2006) Health systems are increasingly being recognised as important to achieving this state of complete well-being, and are defined as “all organisations, people and actions whose primary intent is to promote, restore or maintain health” (WHO 2007) In order to better understand this broad definition, the WHO developed a health system framework Figure shows that this framework consists of six building blocks: 1) service delivery; 2) health workforce; 3) information; 4) medical products, vaccines and technologies; 5) financing; and 6) leadership and governance If one or more of these building blocks are strengthened, the anticipated outcomes are improved health, responsiveness, social and financial risk protection and improved efficiency (WHO 2007) Figure Health system framework building blocks, adapted from WHO 2007 The WHO health system framework in action: Haiti case study Haiti, an impoverished country with a history of periodic political instability, is a fragile state whose health system was threatened by two crises within the year of 2010: a devastating earthquake and a major cholera outbreak (Bengtsson et al 2011) While these two disasters posed significant challenges to Haiti’s healthcare system and served as a threat to the overall legitimacy of the state, the political and social context of Haiti as a fragile state prior to 2010 determine Haiti as a country frequently affected by and particularly vulnerable to crisis (NATO Harvard Project 2012, 10-23) The earthquake of 2010 placed the fragile state of Haiti in a high-impact humanitarian emergency phase of conflict This catastrophic natural disaster not only devastated any Haitian governance and infrastructure but also destroyed much of the resources of the existing foreign humanitarian organisations As a result, the presence and engagement of international actors within most of the country’s systems, including the health system, became of critical importance (NATO-Harvard Project Medicine, Conflict and Survival 2012, 10-23) Significant international response was directed towards short-term solutions to strengthening the health system of the crisis-affected fragile state of Haiti While an immensely difficult and problematic task in a disaster response of such size and magnitude, cooperation and coordinated efforts between the global response community were essential in order adequately respond to the needs of the Haitian population through efforts to strengthen the WHO’s Health System Framework’s six building blocks of the Haitian health system (NATO-Harvard Project 2012, 10-23) In an effort to save lives and protect health post-disaster, the international community impacted many of the WHO Health System Building Blocks (Figure 1) through diverse methods of engagement (NATO-Harvard Project 2012, 10-23) For example, in the six months after the earthquake, multinational responders served to address Haiti’s limited delivery system and healthcare workforce, together treating over 135,000 people In an effort to prevent infectious disease outbreaks, The Ministry of Heath, WHO/PAHO, UNICEF and the Haitian Red Cross launched an emergency vaccination campaign that reached over 150,000 people, therefore significantly strengthening medical supply access Among other donors attempting to address inadequate financial resources, the American Red Cross directly funded the salaries of more than 1,800 health workers in the largest hospital in Port au Prince (Schaaf, 2010) In addition, during the shortly following cholera epidemic, mobile phone technologies provided a means to rapidly disseminate public health information about the prevention of cholera where there were limited healthcare professionals on the ground to give advice (Bengtsson et al 2011) However, in order to continue to improve healthcare in Haiti, a shift from disaster response in support of short-term relief, towards longer-term development initiatives is needed Evidence suggests the international community worked to provide the extensive aid and humanitarian assistance required in the early recovery period of most crisis-affected fragile states (World Bank and IMF 2007) However, the ways in which foreign actors engage in Haiti’s fragile context is of increasing importance as the state progresses into the post-conflict development phase As previously stated, the development progress in fragile states is very much shaped by the presence and engagement of international actors (OECD 2011) Therefore, support should aim not only to protect health but also to encourage a nation’s ability to deliver quality healthcare in the long-term This can be undertaken by directing efforts at strengthening the six building blocks of the Haitian health system (Figure 1) within the context of accountable, sustainable, long run solutions Conclusions Populations of fragile states have a high burden of ill health and are furthest away from achieving the Millennium Development Goals (MDGs) As a result, the international community should be focused on strengthening health systems in these fragile contexts The objectives of these initiatives involve not only health improvement and achievement of MDGs, but also the development of sustainable healthcare delivery, and improvements in human security and wider state building Strengthening such systems is often particularly challenging due to the complexity of factors that accompany these often conflict-affected, insecure settings Contributing to the difficulty, the approaches to strengthening are diverse and dependent on the particular fragile setting However, while creativity is required to address the various elements described, we believe six blocks of the WHO Health M Maruthappu et al System Framework (Figure 1) help to build a quality, equitable, responsive, safe and efficient health system that provides sustainable, long-term solutions Notes on contributors Mahiben Maruthappu is an Academic Foundation Doctor in the North West Thames Deanery, UK Brooke Benton is a student at Tulane University in New Orleans, Louisiana, USA, where she earned her BSc in public health May 2013, graduating summa cum laude with departmental honours Brooke will continue her studies at Tulane University to receive her MPH in global health in May 2014 Brooke has done extensive public health fieldwork in China, Kenya, South Africa and Peru Katharine Harris works as the Programme Coordinator for a Somaliland based health worker Capacity Building Project Katharine received an MA from Oxford University and a Master’s in public policy from King's College London Preeti Patel is a Lecturer in Global Health and Security at the Department ofWar Studies at King’s College London Her research areas include: health in conflictaffected countries with a particular interest in health systems, security, governance; globalisation and health; tracking Official Development Assistance for health; and the causes of armed conflict Brian Godman is a senior researcher at Division of Clinical Pharmacology at the Karolinska Institutet in Stockholm, Sweden, as well as Visiting Professor at Strathclyde Institute of Pharmacy and Biomedical Sciences and National Institute for Science and Technology on Innovation on Neglected Diseases, Centre for Technological Development in Health, Oswaldo Cruz Foundation (Fiocruz), researching strategies to enhance the quality and efficiency of prescribing of both new and existing drugs His research has resulted in an appreciable number of publications during the past few years More recently, Brian’s activities include researching ways to improve health provision in fragile/ transitional states especially given the appreciable proportion of healthcare expenditure that is being spent on pharmaceuticals in these countries He has a PhD from the Open University Alexander Finlayson serves as head of Research at the Centre for Global Health at King's College London with an interest in Health Systems Strengthening in Fragile States He is the deputy director of INDOX, a Research Capacity Building Unit at Oxford University focusing on India and The Gulf He is the CEO of MedicineAfrica, which supports the education of healthcare professionals in hard to reach fragile states He has a BA in both Neuroscience and Medicine, was a researcher at The Mayo Clinic, and then a Kennedy Scholar at Harvard University studying systems biology References Bengtsson, Linus, Xin Lu, Anna Thorson, Richard Garfield, and Johan Von Schreeb "Improved Responses to Disasters and Outbreaks by Tracking Population Movements with Mobile Phone Network Data: A Post-Earthquake Geospatial Study in Haiti." PLOS Medicine 8, no (August 30, 2011) Bisika, T "Health Systems Strengthening in Conflict Situations." East Afr J Public Health 7, no (September 2010): 277-81 Medicine, Conflict and Survival Bornemisza, O., M K Ranson, T M Poletti, and E Sondorp "Promoting Health Equity in Conflict-Affected Fragile States." Social Science and Medicine 70, no (January 2010): 80-88 Call, Charles T "The Fallacy of the 'Failed State.'" Third World Quarterly 29, no (2008): 1491-507 Chandy, Laurence Aiding Stability: Improving Foreign Assistance in Fragile States Global Views 27 Washington, DC: The Brookings Institution, 2011 Coupland, R "Security of Health Care and Global Health." N Engl J Med 368, no 12 (March 21, 2013): 1075-76 DFID (Department for International Development) Why We Need to Work More Effectively in Fragile States London, UK: DFID, 2005 Goma Epidemiology Group "Public Health Impact of Rwandan Refugee Crisis: What Happened in Goma, Zaire, in July, 1994?" The Lancet 345, no 8946 (February 1995): 339-44 Haar, R J., and L S Rubenstein "Health in Fragile and Post-Conflict States: A Review of Current Understanding and Challenges Ahead." Medicine Conflict and Survival 28, no (2012): 289-316 Horton, Richard "Violence and Medicine: The Necessary Politics of Public Health." The Lancet 358, no 9292 (November 3, 2001): 1472-73 Kruk, M E., L P Freedman, G A Anglin, and R J Waldman "Rebuilding Health Systems to Improve Health and Promote Statebuilding in Post-conflict Countries: A Theoretical Framework and Research Agenda." Social, Science and Medicine 70, no (January 2010): 89-97 Lee, K., and C McInnes Public Health, Foreign Policy and Security: A Discussion Paper UK Global Health Programme Working Paper London, UK: The Nuffield Trust, 2003 Magone, Claire, Michael Neuman, and Fabrice Weissman, eds Humanitarian Negotiations Revealed: The MSF Experience Compiled by Medecins Sans Frontieres London, UK: Hurst and Company, 2011 NATO-Harvard Project The Haiti Study: Towards a Comprehensive Response to Health System Strengthening in Crisis-Affected Fragile States N.p.: n.p., 2012 Newbrander, William, Ronald Waldman, and Megan Shepherd-Banigan "Rebuilding and Strengthening Health Systems and Providing Basic Health Services in Fragile States." Disasters 35, no (October 2011): 639-60 OECD (Organisation for Economic Co-operation and Development) Ensuring Fragile States Are Not Left Behind Factsheet on resource flows and trends 2013 OECD, 2013 PDF OECD (Organisation for Economic Co-operation and Development) International Engagement in Fragile States: Can't we better? Conflict and Fragility N.p.: OECD Publishing, 2011 Pavignani, Enrico "Human Resources for Health through Conflict and Recovery: Lessons from African Countries." Disasters 35, no (October 2011): 661-79 Rubenstein, Leonard S., and Melanie D Bittle "Responsibility for Protection of Medical Workers and Facilities in Armed Conflict." The Lancet 375, no 9711 (January 2010): 329-40 Salama, Peter, Paul Spiegel, Leisel Talley, and Ronald Waldman "Lessons Learned from Complex Emergencies Over the Past Decade." The Lancet 364, no 9447 (November 2004): 1801-13 M Maruthappu et al Schaaf, Bryan "Recovery and Health Care in Haiti." Haiti Innovation Last modified August 15, 2010 Accessed July 13, 2013 http://haitiinnovation.org/en/2010/08/16/recovery-and-health-care-haiti Smith, J., and R-L Kolehmainen-Aitken Establishing Human Resource Systems for Health during Postconflict Reconstruction Cambridge, MA: Management Sciences for Health, 2006 Sondorp, Egbert, and Preeti Patel "The Role of Health Services in Conflict-Ridden Countries." Journal of Health Services Research and Policy 9, no (January 1, 2004): 4-5 Stewart, Patrick Weak Links: Fragile States, Global Threats, and International Security Oxford and New York: Oxford University Press, 2011 Toole, M J., and R J Waldman "The Public Health Aspects of Complex Emergencies and Refugee Situations." Annual Review of Public Health 18, no (May 1997): 283-312 WHO (World Health Organization) Everybody Business: Strengthening Health Systems to Improve Health Outcomes: WHO's Framework for Action Geneva, Switzerland: World Health Organization, 2007 WHO (World Health Organization) Figure 1: The WHO Health System Framework Chart Geneva, Switzerland: World Health Organization, 2007 PDF WHO (World Health Organization) Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19 June -22 July 1946; signed on 22 July 1946 by the representatives of 61 States Official Records of the World Health Organization, no Geneva, Switzerland: World Health Organization, 1948 World Bank Conflict, Security, and Development World Bank Development Report 2011 Washington, DC: The World Bank, 2011 PDF World Bank, and IMF (International Monetary Fund) Millennium Development Goals: Confronting the Challenges of Gender Equality and Fragile States Global Monitoring Report 2007 Washington, DC: The World Bank, 2007 ... Laurence Aiding Stability: Improving Foreign Assistance in Fragile States Global Views 27 Washington, DC: The Brookings Institution, 2011 Coupland, R "Security of Health Care and Global Health. "... service provision, as internal state capacities are limited (World Bank and IMF 2007) The way in which international donors engage in fragile states has a crucial role in determining their development... However, strengthening health systems in fragile states is challenging due to a complexity of factors These include high burden of disease, poor governance and leadership, large health inequities (rural