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Globalization and disasters: issues of public health, state capacity and political action.

Historically, the first cycles of globalization began with people trading goods, ideas and rudimentary technology, and migration brought cultures across borders and oceans. Initially, the wealth brought by globalization was limited to a tiny minority of the most fortunate. Only recently has globalization produced sustained living standard improvements in entire societies. (1) This has happened to such a degree that today many people associate globalization with the "opportunity" to gain economic and human security.

Human security, "often referred to as 'people-centered security' or 'security with a human face,' focuses on freedom from fear and want of human beings rather than states." (2) Whereas "human security emphasizes the complex relationships and often-ignored linkages among disarmament, human rights and development," it is suggested here that human security also takes center stage in the way the world appreciates and deals with the impact of large-scale disasters on populations. (3)

Especially in disaster-prone areas increasingly inhabited by the poor, large-scale disasters provide comparative benchmarks that distinguish the haves and have-nots, and often expose deep imperfections in basic human rights protections. Creating socially sustainable forms of disaster management that meet expectations of an increasingly informed, demanding and globalized world population is a major challenge. In reality, such disaster response requires global investment that places human security above state priorities.

Civil society expects that the public health be protected from the consequences of crises, including threatening disasters. Disasters keep governments honest: They define a state's capacity to protect its population while exposing its vulnerabilities to political upheaval in the aftermath of poorly managed crises. These concepts can be extrapolated to a global society and a fledgling global culture. More strongly than ever, the public demands equity and transparency in global public health mechanisms during disaster management.

Global responses to large-scale disasters have, too often, been imperfect, ad hoc and politically motivated. Misguided emphasis is placed on short-term emergency response rather than prevention and preparedness leading to long-term sustainability and improved state capacity. International organizations and governments, often using military assets, have tended to unilaterally aid other states facing disasters.

We must invest in global disaster responses that purposefully reflect increasing expectations arising from globalization. Three elements critically define the requirements and limitations of an investment in global responses: (a) the recognition that public health must take precedence over politics, (b) the depth and reach of a nation-state's capacity to protect public health during crises and (c) the expanding political interference with efforts to coordinate and invest in responses to major disasters. It is argued here that a unique opportunity exists, amid discussions of potential UN reform, to invest in a global disaster response architecture that supports the expectations and demands brought about by globalization and emerging global culture.

Public Health

The Global Cultural Sphere

Elements of an emerging global culture are evident throughout the world. Human development researcher Jeffrey J. Arnett suggests that the generation of the 21st century has already developed a bicultural identity combining individual local identity with an identity linked to the global culture. (4) Never has cultural identity change been more visible than in the formerly silent societies once hidden behind covered openings of adobe huts and refugee tents. Except in the most repressive regimes, the technical elements of globalization cannot be stopped. Massive flows of technology-based, real-time information increasingly build expectations of improved local governance, employment and everyday human security. (5)

Yet major social, economic and political inequities, amplified by globalization, risk increasing the disparities among the world's populations. These disparities are no surprise. Today the world sees media coverage of a local tribal leader in an area struck by an earthquake, looking exhausted and distraught when he finally receives delayed relief supplies to his remote village. The world hears him compare his country's poor response to what he knows is better in other countries half way around the world. And in 2005, Hurricane Katrina exemplified the relationship between disparities and disaster vulnerability in even the wealthiest nation.

The Changing Definition of Public Health in a Disaster-Prone World

Skills and arts passed along to succeeding generations have defined cultural practices in regards to public health, human rights and human survival. (6) When a culture is lost, so too is the inextricably connected professional and institutional memory of public health measures.

More than 50 years ago, environmental and public health professionals were defined by a "narrow sanitary engineering approach." (7) Over the last two decades during complex internal state emergencies in Africa, the Balkans, South America and Asia, the humanitarian community struggled to maintain public health infrastructure. (8) In these cases, the destruction or inaccessibility of protective elements of clean water, sanitation, shelter, food and basic healthcare led to public health catastrophes in which 90 percent of the deaths resulted from easily curable diseases such as diarrhea, malnutrition, pneumonia and malaria, and from the deadly complications of vaccine preventable diseases such as measles, diphtheria, tuberculosis and polio. Although the public usually associates complex emergencies with violence, less than 10 percent of the deaths are weapon-related. (9)

Public health no longer refers only to medical care, but more accurately reflects governance, transportation, communication, public safety, the judiciary and other civil sectors. (l0) This interdimensional public health is defined globally as both a national and international responsibility that must be adhered to in any crisis, not just war and conflict. Technically and politically, the international public health community has mobilized accordingly. For example, the Red Cross Movement now staffs and regularly deploys over one hundred water and sanitation professionals to major emergencies worldwide.

What happens locally, whether a region-wide natural disaster or a highly communicable disease, has immediate global ramifications. Thus people around the world now look to governments to support public health as part of their international responsibilities. With the influence of globalization, all that differs between nation-states is the quality and quantity of otherwise similar public health programs and the desire to improve them. Nation-states, for the most part, recognize that the core functions of public health transcend national sovereignty and include promotion of international research, development and sharing of scientific advances and participation in the surveillance of infectious disease.

Even in the midst of wide multicultural diversity, public health is the bridge to a common ground and the source of shared security. This concept is readily understood without the necessity for translation. Much of the public health community "is increasingly seeing itself as a political actor capable of influencing world affairs and is carving out a role for itself in combating poverty, inequity and unsustainable development." (11)

Disasters--complex, natural and technological--have come to define public health vulnerabilities in infrastructure, organization and leadership. Even small-scale disasters requiring cohesive sociopolitical and economic interventions help define a country's public health capacity. These occurrences can reveal vulnerabilities and inequities that, unless addressed, typically lead to future problems. A number of factors can contribute to future complex emergencies: (1) urbanization of global populations; (2) the demographic prevalence of the world's poor in urban settings; (3) failing public health infrastructure; (4) lack of moral integrity of governments; (5) availability of and access to weapons, including weapons of mass destruction; (6) economic inequities and corruption; (7) undisciplined military, paramilitary and police; (8) suspension of the rule of law; (9) wanton violations of protective treaties; (10) failures in environmental and ecological security; (11) food and water insecurity; and (12) transmigration of populations due to conflict or political, economic and environmental issues. (12)

Disasters keep all of us honest. For example, when fledgling Central American democracies of the 1950s failed to provide adequate public health responses to natural disasters, they succumbed to the pressures of rival political parties and military coups. (13) No country is exempt from shouldering the responsibility of protecting the public health. Furthermore, no country can simply rely on faulty claims of robust disaster preparedness without risking disastrous consequences. That over 100 countries and UN agencies offered aid to the United States after Katrina was for some a national embarrassment, suggesting that countries that have previously experienced these kinds of events recognized the public health emergency of Katrina before the United States did. Yet individual nation states, regardless of their resources, do not always have the capacity to address many conventional or modern day problems such as the regional impact of an earthquake or religious- or ethnic-based security concerns.

Globalization and Public Health

Whereas humanitarian action is synonymous with restoring public health, the word "humanitarian" is a relatively new term. In many languages it does not even exist. The "idea of a country or a people or even the international humanitarian community having a responsibility for a particular people's calamity is also relatively recent and by no means universally held." (14) If a globalization framework for human security were to exist today, its standards would be defined in response to the same natural disasters that were present, but neglected, during the 1950s. The 2004 Indian Ocean tsunami and Hurricane Katrina gave the world an opportunity to overcome the barriers of nation-state sovereignty and multiculturalism through unprecedented collaboration and informal self-organized networking of local populations with international agencies and organizations. Hurricane Katrina was unique in that the U.S. government accepted bilateral and multilateral relief aid, a rare event in modern times. (15) In the aftermath of the Indian Ocean tsunami, enough formal external resources prevented the public health emergency from developing into a secondary disaster. Rapid deployment of Red Cross Movement emergency response teams prevented any major outbreak of disease from contaminated water and sewage. (16) It was no accident that, once the tsunami hit, a strong public health emphasis from national and international aid thwarted further deaths.

Given the growing transnational movement of people and goods, globalization is increasingly interconnected to security, the authority of the nation-state and public health. The SARS pandemic emphasized the accelerated international movement of an infectious disease and called into question the capacity of the public health infrastructure to meet such challenges, especially when public health is compromised by economic globalization pressures. (17) Policymakers must address the interconnected challenges posed by mass migration, international terrorism, global warming, epidemics, large-scale natural and technological disasters and the complexities globalization brings to the detection and management of these major events. (18) However, references specifically linking globalization and disasters are few in number. To date, research has primarily concentrated on globalization's economic impacts on the incidence of and response to natural disasters.

Globalization and increased poverty and war have prompted humanitarian assistance to move from a rural to an urban setting. In the 1990s, 80 percent of the world's population growth occurred primarily in African and Asian towns and cities. In 2005, one-half of the world's population lived in urban areas, crowded onto just 3 percent of the earth's land, most of which is disaster-prone. (19) Over 67 percent of the former rural population of Africa is now in high-density, infrastructure-poor cities. This alarming increase in population density correlates with overpopulation concerns and has significantly altered our approach to public health.

Arguably, public health has not kept up with the rate of urbanization. However, only recently have processes of urbanization, industrialization and globalization highlighted the need to address a broader understanding of health and environment-related issues in the context of sustainability. (20) The health impacts of globalization and the expectations of health consequences within an environment given varying factors such as geographical location, gender, age, ethnic origin, education level, governance and socioeconomic status must be given greater consideration. (21)

In complex emergencies, health facilities are the first to be destroyed and the last to be rehabilitated. Even after conflicts subside, health and public health infrastructure are rarely recovered. Predictably, the vulnerability threshold is lowered even more and subsequent disasters take an added toll on the victims. (22) As part and parcel of any recovery process that leads to sustainability, health must be recognized as both a strategic and security requirement. Indeed, the earliest measure of declining political security leading to war is subtle worsening of health indicators as reflected in increased morbidity and mortality rates. (23) Therefore, for over two decades, all relief sectors--water, food, shelter, sanitation and health--routinely use health indicators as the most sensitive measure of success and effectiveness of the aid process. (24)

Despite massive information flow, old ideas linger and change comes slowly. Some continue to see disasters as the result of "misfortune, of randomness, the forces of nature, or the whim of gods or of God," a subset view natural disasters as God's handiwork not to be interfered with by scientific study or prevention. (25) in the early 1970s, Life and Look magazines depicted marasmic children from the Biafran conflict, leading shocked citizens from developed countries to demand that political leaders intervene with the Nigerian government to stop the senseless debacle. Today, rather than stimulating donations and volunteerism, depictions of the worst conditions are becoming so commonplace that they fatigue donors and invoke skepticism.

Still others fear that this new global culture will lead to the disappearance of local uniqueness or the loss of cultures, each of which has contributed in some form to progress. Displacement, disappearance and assimilation of refugee populations into different cultures raises the question of whether the abrupt loss of a culture, and its public health advances, should be addressed as a global strategic, political and security issue. With international resources to protect cultures at risk, the test of such measures would be played out in the protective management response of a large-scale disaster event. Thus, in general, and if given the opportunity, the international community of states, while hanging onto their individual sovereignty, could agree that public health status be a universal indicator for measuring the effectiveness of state capacity.

STATE CAPACITY

Defining and Measuring State Capacity

Thomas Homer-Dixon, a major scholar in the field of environmental security, defines state capacity as the "government at all levels of power and/or capability to maximize its prosperity and stability, to exert de facto control over its territory, to protect its population from predation, and to adapt to diverse crises." (26) In short, state capacity defines the capability of a government to protect its citizens from the consequences of a crisis.

The new issue of public health equity in disaster management has rapidly grown roots that are clearly related to state capacity. For example, the Humanitarian Policy Group determined that humanitarian assistance is a distinctive subset of aid policy in donor governments and must establish "good donorship" mechanisms by which aid resources are allocated according to need. (27) Greater international awareness of successes in protecting local and national health capacities from crises has resulted in a better understanding of what would be required in making a global health investment for disaster recovery. For the first time, the globalization of public health has leveled the playing field of "health expectations." (28)

Still a nation-state may require additional outside action during disaster response to meet the standard expectations of global health. This was painfully obvious when the United States failed to deliver in New Orleans after Hurricane Katrina, raising the question of whether there are other potential public health emergencies not yet recognized. The primacy of public health concerns is apparent in the developing world where public health infrastructure has disappeared or steadily declined. Arguably, the need to address un-rehabilitated and outdated public health infrastructure, such as levee systems, also exists in the developed world. Yet, too often it takes a major disaster to expose what needs to be targeted for infrastructure repair.

State capacity should be quantifiable. Such indicators can be correlated against other parameters (e.g., population, resource scarcity, health, technology, public health infrastructural investments and environmental degradation). The state capacity to manage disasters can be measured by determining vulnerability or the potential to suffer harm or loss, and resilience or speed of recovery in activities that repair and replace what was lost or damaged. In turn, the measured level of state capacity determines a nation-state's ability to satisfy its most important needs: survival, protection of its citizens from physical harm, economic prosperity and stability, effective governance, territorial integrity, power protection and ideological projection. (29) State capacity can be partial (regionally within a state) or complete (national). For example, the South Asia earthquake of 2005 revealed territories in which the central governments had little influence or capacity to be effective, not unlike Katrina.

Andrew Price-Smith, a scholar and researcher of globalization, suggests that a sensitive measure of capacity is a state's ability to manage an infectious disease outbreak. (30) Epidemic investigation and control requires a fairly sophisticated lateral decision-making and resource coordination system which is inextricably tied to good governance, adequate funding, accountability, transparency and the ability to manage resources. Countries with poor governance and low levels of state capacity have failed to contain the spread of a contagion and mitigate its economic and political toll. A case in point is the steady decline in Zimbabwe's governance capacity that has contributed to an escalating HIV/MDS epidemic. (31) Those familiar with the nuances of international health practice will appreciate that 75 percent of worldwide epidemics during the last two decades occurred in countries where war and conflict left little or no state capacity. (32) In these countries, the relative destruction wrought by disease, compared to deaths from military actions, is a statistically significant 52:1. (33) In each epidemic, the country depended almost exclusively on external humanitarian resources to manage the outbreaks.

Furthermore, a strong positive correlation exists between population health (measured by life expectancy and infant mortality rates) and state capacity In a study of twenty nations over forty years, Price-Smith demonstrated that public health is a "major driver" of state capacity and that significant declines in population health will generate significant declines in capacity over the long-term causing a "reciprocal spiral dynamic" between public health and state capacity. (34) Emerging and reemerging infections, especially HIV, constitute a growing threat to international development, governance and state capacity, while contributing to a dwindling "reserve carrying capacity" Several factors influence a nation-state's adaptive capacity for emergency response: (35)

* The initial level of state capacity determines the scale of adaptive resources that may be mobilized during times of crisis;

* States with higher initial capacity have greater technical, financial and social resources to adapt to crises;

* State adaptation is affected by exogenous inputs of capital, social and technical ingenuity; courtesy of actors such as international organizations and outside military assistance;

* State capacity to adapt may be compromised by certain outcomes generated by intervening variables such as war, famine and ecological destruction (e.g., deforestation, overuse of agricultural land).

State capacity is also driven by value systems and political will. High funding for emergency response correlates with nation-states possessing high levels of state capacity. Nevertheless, in the United States, Katrina exposed gaps in state capacity, notably the Federal Emergency Management Agency's prior organizational change, poor leadership and decreased funding stream. In the developing world, low initial levels of state capacity mean that the least developed societies face the greatest risk from global spread of infectious diseases. (36) Thus, infectious disease prevention and outbreak containment become sensitive measures of state capacity. One can easily extrapolate that high levels of disease prevalence and its effect on state capacity would correlate with other vulnerabilities, including large-scale natural disasters.

An additional state capacity indicator affected by globalization is the status of the workforce health. The brain drain of health care workers from less affluent countries and regions to more affluent areas depletes human resources from countries with the greatest health needs. The overall shortage of healthcare workers throughout the world has reached crisis proportions. Foreign physicians make up 25 percent of those in the United States, 60 percent of whom are from developing countries. (37) Lincoln Chen, a distinguished professional of international public health and development at Harvard, suggests that analysis of the global health workforce is critical to the mobilization and strengthening of human resources and central to "combating health crises" in poorer nations. He proposes that effective strategies should be a "shared responsibility" backed by "international reinforcement." (38)

Moreover, modern day wars, often characterized by intimidating threats to civilians and assassinations of intellectuals and professionals, may lead to a rapid decline in workforce capacity in developed cultures. Iraq, formerly referred to as the "medical pearl of the Middle East," has experienced an increasing brain drain of experienced health care providers with worsening security, ransom kidnappings and ministry-level corruption. (39)

Globalization and Disaster-specific State Capacity

State capacity will vary with the population type, size and familiarity with the disaster. Complex emergencies, such as the conflicts in Somalia, Liberia, the Congo, East Timor and the former Yugoslavia, represent the most common human-induced disasters of modern time and have preoccupied the world's attention and resources since the end of the Cold War. Technological disasters can result from an accidental release of biological, chemical or radiological substances or from deliberate acts of terrorism. In the last two decades, complex emergencies and technological or terrorist threats have preoccupied many governments. Fortunately, deadly internal conflicts are declining in number and violent deaths worldwide have, in fact, dropped dramatically since the early 1990s, while the number of conflicts resolved by negotiation has risen dramatically. There is ample evidence to show that the international community has improved its efforts in preventive diplomacy. (40) But the consequences of two decades of violent internal wars remain unresolved and increasingly dire in places such as Somalia, the Sudan, the West Bank, the Gaza Strip and refugee camps and enclaves of internally displaced populations scattered around the developing world. Many such populations have been given no choice but to settle in areas prone to natural disaster.

Natural disasters can be defined as "the occurrence of an abnormal or infrequent hazard that impacts on vulnerable communities or geographical areas, causing substantial damage, disruption and possible casualties and leaving the affected communities unable to function normally." (41) In terms of the range of natural phenomena, these events are usually both uncommon and extreme. However, exposure to geophysical hazards appears to be rising, due in part to migration and population growth in areas most at risk to these hazards (e.g., coastal populations, earthquake prone Pacific Rim nations). Confusion exists as to the causality of an observed rise in frequency of natural disasters in the past decade. The exceptional disaster patterns in 2005 raise yet more difficult questions about disasters and their possible interactions with nature and society (e.g., anthropogenic environmental change, poverty, population settlement patterns). Evidence-based science since the 1950s has shown that the deaths and damage resulting from natural disasters are more representative of societal factors than of the naturally occurring event itself. Major natural or technological emergencies are not conceptually separate from complex internal conflicts if a state's capacity is limited or disrupted: All are evidence of major public health deficiencies; all may catalyze worsening political violence; and all expose a lack of proper resources to respond, a lack of security and management capacity and the benefiting of politically favored populations.

Poor nations usually bear the brunt of natural disasters in terms of fatalities: 96 percent of all deaths from natural disasters occur in developing countries. (42) In 2005, over 300,000 lives were lost and over $100 billion in damage occurred in poor nations from natural disasters, primarily from high seismicity. (43) Rapid urbanization, a process often associated with globalization, creates large concentrations of people and physical capital. These congregations of the disenfranchised mostly settle on coastlines, and their dwellings are at risk from poor, nonexistent or criminally violated construction codes, no emergency back-up systems and little regard for natural hazard vulnerability. (44) Whereas the absolute number of natural disaster events may not be increasing, the growing vulnerability of populations certainly is. Overpopulated urban zones in disaster prone areas, where increases in hunger, poverty and environmental degradation are common, heighten the impact of a disaster event. The resulting consequences of displacement, lifelong disability, loss of livelihood and death are the direct and indirect result of globalization.

As increased disaster losses parallel the advance of globalization, researchers question whether the two trends are related or coincidental. (45) Documented population growth, poor zoning and land overuse in disaster prone areas as a product of globalization would argue for the former explanation. The reported global costs of natural disasters has risen significantly, with a fourteen-fold increase between the 1950s and the 1990s. (46) Globalization and its rising costs also correlate with an increased sensitivity to the effects of natural disasters, exposing countries to new forms of risk and exacerbating the impact of disasters when these risks coincide.

Natural disasters can also trigger an increase in interest rates, catalyze capital flight and create crises in the balance of payments, ultimately compromising a country's ability to participate further in the global economy. The "reserve carrying capacity," a critical buffer in state capacity, suffers in the aftermath of a disaster when a government obliged to meet budgetary pressures increases the money supply, draws down foreign-exchange reserves or increases borrowing. All place future strains on an already fragile economy. (47) Additional studies discuss "demographic entrapment" whereby nation-states suffer over-consumption, particularly of natural capital and environmental degradation. In time, their overall reduced reserve capacity risks devolving into regional conflict (often due to regional competition of available resources, such as water and oil) and increased frequency and sensitivity to natural disasters. (48)

Other studies suggest that more disaster-prone low-income countries may experience a relatively slower rate of economic growth than their less disaster-prone counterparts with similar levels of per capita income. All disasters disrupt long-term investment plans both in physical and human capital. (49) The World Bank confirms that the potential long-term impact of natural disasters affects capital accumulation, growth objectives and policy options in dealing with subsequent disasters. Nation-states may divert resources from planned investments to fund relief and rehabilitation. (50) From the donor community, disaster-related external assistance may replace external development assistance. Some disaster-destroyed assets may never be replaced, contributing to an environment of instability and uncertainty that further discourages new investments. (51)

In some regions, globalization has increased poverty and the need for services. (52) Public cutbacks have reduced the ability of state agencies to deal with conflicts and humanitarian crises as they arise. The declining official developmental assistance funds have increased competition for resources among international NGOs and their national-international alliances. (53)

State Capacity and Sovereignty Concerns

Although not explicitly stated, there are critical links between state capacity, sovereignty and international law. Few if any nation-states have the capacity to deal with the consequences of large-scale disasters necessary to protect their population. (54) A healthcare system's ability to respond to increased demand is often required during the immediate and early aftermath and again post-disaster. This surge capacity and awareness that outside assistance may be necessary pose challenges for state sovereignty. In the pre-SARS era, countries lacked a substantive framework for an integrated international response to any potential biological disaster, deliberate or accidental. (55) Concerns, if they existed, were more political and economic than health-related. Furthermore, the World Health Organization (WHO) relied on 192 UN member states to voluntarily report domestic outbreaks. Yet once they learned of an outbreak, they could only offer "advice and limited resources" so as not to violate a nation's sovereignty. This sovereignty-led approach contributed over the years to many cultural fears and internal political squabbles over outside pressure to comply, resulting in the hampering of national immunization and eradication programs for polio and other infectious disease outbreaks. (56)

The SARS incident was a watershed event in globalized public health disaster response. Because official Chinese dissembling delayed accurate reporting, SARS spread rapidly to forty countries in ten days, severely impacting the economy wherever it spread. (57) SARS provoked global concern, increasing demand for cooperation and response in future disease outbreaks, and pressed nation-states to be more transparent in reporting infectious diseases that represent a global threat. Most critically, SARS awakened a lethargic international public health system and opened a wide and seemingly unobstructed opportunity for global action based on interdependence and international collective action. (58) When the World Health Assembly Ministers passed permanent International Health Regulations (IHR) giving the WHO the authority to enhance their global health surveillance system and require nation-states to participate, a clear declaration was made that public health takes precedence over politics. In future outbreaks, under authority of the IHRs, the WHO can enter a country with regionally-placed teams of experts and supplement that nation's resources in order to protect global public health. (59)

However, there are tensions between those who singularly demand strong control measures and those in government who insist that economic trade not be compromised, no matter how severe the outbreak. Due to the economic repercussions of SARS, the new IHR strives to strike a balance in its language between disease outbreak control and a country's concerns for safeguarding economic trade, making negotiations for international regulations a worthy subject for students of globalization. Furthermore, an international legal mechanism is critical for surge capacity to work in countries attempting to meet "essential functions in direct management of provisions of services and the control of the international transfer of health risks." (60)

The SARS outbreak changed the nature of all disaster challenges, not just those of an infectious origin. All countries must now deal with the international transfer of risks as part of globalization. Achieving these objectives, however, is beyond the scope of any one nation-state's sovereignty or capacity and requires the collective establishment and enforcement of international norms and standards. Globalization, specifically the globalization of disasters, must leverage experience with IHRs to provide a code of conduct for responding to and reporting transnational public health threats. (61) This major step undeniably represents the precedence public health takes in decisionmaking priorities.

The globalization of public health threats require globalized legal approaches. An "expansive" view of these reforms includes the language for timely and efficient responses, the reduction of disaster vulnerability and the utilization of core "public goods" to ensure international health cooperation. (62) Some have argued that an international law-based globalization approach provides an "international framework of rules and enforcement methods" that aids sovereign governments to "decide, design, and enforce rules which, in fact, can protect the individual citizen from the worst excesses of the state." (63) In a sense, a matured process of globalization can properly function like international law. Furthermore, such actions utilize both a human rights and an ethical argument to justify the international community becoming an "agent for the dispossessed" for "a variety of circumstances including natural or artificial disasters." (64)

POLITICAL ACTION

Always lurking and often contradictory are the political environments of two strange bedfellows, the United Nations and the post-Cold War U.S. government. Both possess essential assets and legitimacy for responding to global disaster. Yet both come to the table with opposing political motives and inherent institutional limitations that, at best, provide an incomplete solution to what a global response should be.

The United Nations

From the 1945 signing of the UN Charter to the end of the Cold War, UN capacities to intervene in peacekeeping and humanitarian relief were severely hampered. In 1992, the UN Security Council approved, for the first time, an international relief response to the Kurdish crisis. Until then, humanitarian action was considered to be an activity not to be tarnished by political or military entanglements. The 1991 Kurdish crisis was considered a success in part because the military limited their role to providing security and infrastructure assistance to a fledgling community. Since that time, all UN agencies, and even the International Committee of the Red Cross (ICRC), have found themselves in increasingly controversial, if not competitive, humanitarian, political and military activities. (65)

All too often, the United Nations is falsely perceived as an international governmental body with the capacity to respond to a number of international crises. The UN Charter is an outdated, non-supportive and restrictive legal document written at the conclusion of the Second World War to prevent future cross-border conflicts. The secretary-general presides, he does not rule. (66) Unfortunately, an opportunity fifty years ago to implement Article 43 of the charter, which would have provided for a UN Standing Task Force, was strongly resisted. Its passage would have included participation of the force in large-scale natural disaster response. Instead, it takes months to convince governments to contribute forces to an urgent mission that has not even caught the attention of the Western press.

Yet despite tremendous limitations, a more effective UN disaster response portfolio has slowly emerged since the end of the Cold War. Credible performances, especially in management and coordination, occurred in complex emergencies such as East Timor and Liberia. Current response capabilities for international disasters arise from the Office for the Coordination of Humanitarian Affairs (OCHA) which can deploy Military-Civilian Disaster Assets (MCDA), coordinate UN agencies and summon the Red Cross Movement and international NGOs--all of which make up an operational level "humanitarian community." (67) For example, during the highly visible airlift of food into Afghanistan in the winter of 2001-02, the U.S. military delivered only a tiny fraction of the total amount of food aid. Steven Hansch, a respected researcher of complex emergencies, emphasizes that the "NGOs and the World Food Program (WFP) have every bit, and more, capability to transport goods across countries and continents than the military, and at a cheaper rate." (68)

Politics of Disaster Response and the U.S. Military

Events since September 11th have severely hindered possibilities of a unified effort to create a global disaster response system. Since then, the U.S. government has exclusively seen all crises as security issues, even those in which it provides substantial humanitarian relief. In current U.S. response doctrine, political action translates into military action. For instance, the U.S. military initially categorized the Indian Ocean tsunami as a complex emergency, a title the humanitarian community reserves for internal wars.

The lack of a robust arsenal of assets to rapidly field logistical, transportation and communications resources hinders the United Nations and the humanitarian community's effective emergency response. In the short-term, the U.S. military has an obvious advantage since it already owns airlift assets, but in the long term, the United Nations and NGOs can also lease equipment such as C-130s and helicopters.

Because civilian agencies have demonstrated little capability to meet the critical short-term logistical requirements of a disaster, more able and better-equipped militaries like the United States' should respond in the short-term. The entire humanitarian community cannot match the military's ability to rapidly deliver real-time airlift and mobilize maritime operations, especially to small islands or at sea.

However, the opportunity for the U.S. military to respond rapidly is often more a matter of circumstance than consistency In 1992, a U.S. naval armada returning from the Persian Gulf War via the Indian Ocean assisted in the immediate aftermath of the Bangladesh cyclone. Likewise, the war in Afghanistan allowed nearby helicopters easy access to the South Asia earthquake victims of 2005. The maritime military alone provided critical access for search and rescue of boat people and for reaching the coastlines of tsunami-affected areas in Aceh, Indonesia. In the response to Katrina, a 2006 Congressional report confirmed that military assistance was invaluable, but the military assistance failed to coordinate with state, local and other federal assistance organizations. (69)

The military also has a strong advantage in its worldwide corps of health experts. For example, the Department of Defense (DoD) controls an international network of Army and Navy laboratories that has historically collaborated with the WHO and other international organizations. (70) Although the military often rapidly deploys surgical teams, resources addressing public health and preventive medicine are better suited for the majority of disasters. The earlier the public health infrastructure assessments are completed, the faster resources can help public health recovery. Here, the military has a wealth of service-recognized expertise, such as laboratories, which can assess and manage public health problems in austere environments. Examples of operationally focused teams of public health experts include the Combatant Command's Naval Preventive Medicine Units (NPMUs) and Naval Medical Research Units in Egypt, Peru and Indonesia. (71) Also the military medical corps' history of collaborating with civilian entities enables easier cooperation with the WHO to respond quickly to infectious disease epidemics.

Political-military interest and expertise is often limited by the nature of its assets and by waning media and political interest in the long-term consequences of the disaster. Characteristically, the political-military partnership, while simplifying potential bureaucratic complexities, fails to integrate timelines and visions with non-governmental and UN agencies. It does not possess the capacity to share information, only assets. Imagine instead a global response system in which the superior resources now allocated to the political-military partnership were instead directed to the historically underfunded humanitarian community that must, everyday, struggle to remain operationally alive.

Lastly, assessments of military-led relief are rarely evidence-based. Unquantifiable achievement indicators are routinely used to measure success in such scenarios. Resistance to adopt universal outcome indicators or to accept a shared surveillance policy remains a critical point of contention between the humanitarian community and the military. This lesson was painfully learned during the 1989 Operation Lifeline Sudan when mortality and morbidity rates climbed despite a seemingly robust international relief program. This demonstrated that a political-military's relief mission should use commonly-held humanitarian indicators to monitor the actual outcome of assistance.

Contradictory Priorities

The humanitarian community intends to save lives and protect the public health. In contrast, an admitted U.S. priority in the 2005 South Asia earthquake response was to show a favorable face of the military to the affected civilian population. Author Robert Kaplan suggests that in recent years the military has shifted "emphasis from 'direct action' to the 'soft side of unconventional war' undertaking relief work" with the objective to "win goodwill and informally, to pick up intelligence on America's terrorist enemies." (72) Critics from the humanitarian community view these relief actions with suspicion. Kenny Gluck of Doctors Without Borders states:
 With the aim to win hearts and minds, militaries provide aid
 in accordance with political or public relations priorities,
 not necessarily to those most in need. Witness the huge
 military support to aid efforts after the South Asia tsunami
 versus the meager assistance offered to the millions of people
 displaced by conflict in Congo. (73)


Furthermore they see militarized aid as a "political tool ... when it is seen as part of a political agenda in natural disasters or war." (74) Recognizing the benefit of such a shift, 2005 DoD operational policies call for stability operations as "activities that support U.S. Government plans for stabilization, security, reconstruction and transition operations, which lead to sustainable peace while advancing U.S. interests" and gives to these activities a "priority comparable to combat operations." (75) "Stability operations" has become a catchall phrase that includes former DoD humanitarian activities and programs.

The U.S. priorities are backwards, too often prioritizing immediate intervention over preparedness and prevention. Yet preparedness and prevention are always a better way to solve basic, long-term threats to security in any crisis. (76) Real and potential health consequences of large-scale disasters are global concerns and require unparalleled coordination within the international community. A multilateral response must be revitalized but requires a global investment which at this writing has little political likelihood.

The profoundly contradictory history of globalization between the "have and have not" countries makes it crucial that policymakers better understand and manage globalization processes in the future. When the military responds to a disaster, the accompanying political message of winning the hearts and minds of the people undercuts opportunities to provide sustainable programs after the military exits. Such a maturing, cultural change for the military requires a commitment to education and training, greater cross-cultural skills and the will to combat the socioeconomic inequalities that tend to be revealed by the disaster and exaggerated by globalization. It may be a politically driven mandate for militaries to ignore larger inequities at the time of a disaster response, but the humanitarian community does not enjoy or desire that luxury. Although the humanitarian community pointed out these critical lessons years ago, the U.S. military is only now painfully learning them.

The Emerging Role of Disaster Capitalism

Rapid response to complex emergencies and large-scale disasters has traditionally been the domain of UN agencies in collaboration with international and national NGOs. In 1997 following a three-decade-long humanitarian imperative of focusing assistance in the sectors of health, shelter, food, water and sanitation, NGOs and the Red Cross/Red Crescent Movement created the Sphere Project. This initiative provides standards for humanitarian assistance in all sectors and serves as an operational framework for both priorities and accountability in disaster assistance efforts. (77) The development of the Sphere standards led the humanitarian community to the common belief that, in all sectors, public health must be recovered and analyzed in the post-disaster phase before long-term sustainability planning can occur. (78)

Many complex emergencies emerged in the post-Cold War era. Characteristically prolonged multinational humanitarian aid unwittingly risked providing succor to the internal struggle, prolonging the violence and failing to generate a political solution. This jeopardized the humanitarian imperative and raised concerns over the seeming futility of repeating the conventional post-conflict planning and recovery of previous decades. In response, the Bush administration forged a new doctrine, first fully initiated in the 2003 war with Iraq and later in the response to the Indian Ocean tsunami and Hurricane Katrina, which shifted the emphasis to active reconstruction and poverty reduction through profit-making. Weary of this unilateral move to bring disaster management and recovery into a "more rational direction," and witnessing the slow pace and mismanagement of reconstruction projects in Iraq, early critics suggest that this was nothing more than the "rise of disaster capitalism" in which the U.S.-favored World Bank oversees lucrative, private sector involvement in disaster relief. (79)

These for-profit schemes, many under the guise of disaster relief and humanitarian assistance, vary from preemptive action on nation-state failure, to avoidance wherever possible, to quick response. The plan suggests a role for preemptive planning for rapid response teams to mobilize and deploy pre-negotiated contracts for privatization of public utilities, airports, seaports and highways and pre-contracted public-private partnerships for governments, corporations and foreign donors--all to rebuild what business-politicians see as most "appropriate" for a high-risk country's future. The Department of State (DOS) Office for the Coordinator for Reconstruction and Stabilization (S/CRS) was set up to monitor a "watch list" of high risk and fragile states and "improve coordination, planning, and implementation for reconstruction and stabilization (R&S)." This presidential directive instructs that "building global capacity" will occur when U.S. agencies, with DoS in the coordination lead, "work with key partners on early warning, prevention, and conflict response." (80) Depending on the situation, these operations can be conducted with or without the U.S. military.

The trend since the Balkan wars to militarize and politicize humanitarian assistance has made it increasingly difficult for international relief organizations to maintain their critical neutrality and impartiality. The current unilateral model devalues the roles of the UN secretariat, UN agencies and NGOs. In the run up to the war in Iraq, U.S. senior planners anticipated that the rapid humanitarian and reconstruction success they hoped for would precipitate the demise of the United Nations and disappearance of many NGOs. These longstanding members of the conventional humanitarian community were considered to be both "ineffective and inefficient." (81)

The U.S. political-military partnership must recognize the finite capabilities of armed forces, the extent to which assets and resources are consumed and their potential incompatibility with disaster-specific requirements. To be successful, the United States must learn from past reconstruction and rebuilding efforts that have shown mixed results and doubtful commitment. The reality is that these processes are enormously complex, costly and rarely sustained beyond a call for free elections. (82) The current blame game focuses on lack of security in Iraq, but over time, expensive public health reconstruction projects like water and sanitation will be undermined by budget cuts or costly delays, proving in the end to be more detrimental to the population. In reality, it will be impossible for the Bush administration to sustain a high degree of consistency or adherence to specific interventions except in countries in which the United States shares economic or security interdependence.

A GLOBAL INVESTMENT IN DISASTER MANAGEMENT

The concept of human security seeks to capture the complexity of interrelated threats associated with internal wars, genocide and the displacement of populations. "Proponents of the broad concept of human security argue that the threat agenda should include hunger, disease and natural disasters because these kill more people than war, genocide and terrorism." (83) In its broadest sense, the agenda would encompass economic insecurity and "threats to human dignity." (84) Every country has some response capabilities but no country has a perfect system, especially where large-scale threats challenge the integrity of the public health and security apparatus.

Approaches to human security are complementary to the concept of the globalization of disaster management. (85) In sharp contrast to the current unilateral political-military model, globalization of disaster management, which clearly has a basis in human rights law, would require no biases, political or otherwise, and would promote a transparency and accountability not found in the current model. The process for developing a global investment system and architecture for managing disasters includes several steps requiring major reforms in international organization.

Step one is to favor a human rights-based, global-legal approach that reflects the geopolitical reality of a global culture, not a global power. When human rights treaties are drafted, public health should be recognized as the primary responsibility of individual nation-state governments. The consequences of globalization have driven many nation-states to increase their reliance on non-state actors (such as NGOs) for the management and delivery of health systems, developmental assistance and disaster management. (86)

Unfortunately, the current reality is that a global vision is missing primarily because any recommendations for investing in globalized disaster management would be politically unpopular and a radical departure from the way things are done. (87) Whereas disaster response is a measure of political action, it must be taken outside the political sphere of state influence and self-interest. As suggested by the successes IHRs established for the WHO in disease outbreaks, this process compelled international organizations, such as the World Health Assembly, composed of health ministers from UN member states, to think operationally not just politically There is some consensus that similar global legal approaches should be applied to other global threats and that the international community must compel unwilling nation-states to conform to international standards of behavior.

Step two would be to open a dialogue among countries to address their individual and collective responsibilities for past failures and insist that future crises be dealt with in a professional and non-political manner. Little or nothing is being said about the basic political problems countries have in sustaining human security from the consequences of urbanization, poverty and disasters. Governments that call for radical improvement at the United Nations must also be willing to improve themselves.

Step three is to revitalize the multilateral process, especially in contrast to the confusion and uncertainty brought about by the mismanaged unilateral response to the anticipated weapons of mass destruction (WMDs) in Iraq. Multilateralism is the only road to a global response mechanism. "Most nations are eager to seek multilateral responses in order to share the economic, political and defense burden of large-scale crises." (88) Also, "many countries can only afford to support multilateralism when multilateralism supports them," especially in response to a large-scale disaster event. (89) This could be achieved by promoting and moving further from a culture of "unilateralism" to a culture of "interoperability" among international organizations and systems that emphasize the pooling of knowledge and resources. (90)

Step four is to radically modernize the UN Charter to make possible a predictable international response. This translates into the implementation of an Article 43 UN Standing Task Force to deal with light ("soft power") security crises arising from natural and technological disasters with expanded roles and responsibilities for other global threats. (91) This process would complement the NGO and UN agency response without forcing allegiance to a unilateral military power. (92) Involving all governments under a reformed UN Charter would dilute political interference by any one government. Those advocating for such an implementation will find themselves under heavy fire from political nay-sayers. Whereas a majority of UN members would undoubtedly support such reform, near-term change is unlikely given the general privileges of power and, more specifically, U.S. treatment of all crises as strictly related to security. Unless there is a radical departure from the DoS/DoD for-profit approach to disaster relief and reconstruction, the United States will never voluntarily give up its post-Cold War hegemony.

Step five is to develop system architecture appropriate for a global response to disasters. Recent advances in UN agency capacity, the ability to identify sector-led responsibilities, and logistics and management expertise suggest that an OCHA-led UN response framework would be a suitable building block for a global system. (93) The OCHA Emergency Relief Coordinator (ERC) currently provides leadership to an Inter-Agency Standing Committee (IASC). By involving key UN and non-UN humanitarian partners, the IASC coordinates with major humanitarian actors and, with the ERC, develops humanitarian policies, agrees on a clear division of responsibilities for the various aspects of humanitarian assistance, identifies and addresses gaps in response and advocates for the effective application of humanitarian principles.

UN membership seems to back such a proposal. Such a "robust UN capability to prepare and manage peace operations...would be respected by the international community and help restore UN credibility." (94) The key is to discuss inter-governmental and multilateral cooperation and planning in ways that do not violate sovereignty, ensure public health, reinforce and build state capacity, promote good governance and limit the adversities of globalization. Various levels of professional expertise will require both civilian and military capabilities. This system would federate a large number of humanitarian actors, the UN Standing Task Force and the specific disaster-related expertise of developed world militaries to build this much-needed rapid response capacity.

A recent notable example of UN capacity building is the coordination expertise provided by the OCHA-led Humanitarian Information Center (HIC), which encompasses UN Agencies, NGOs and donor entities. The HIC collects, integrates and disseminates information and data in a number of complex and natural disaster settings. It provides up-to-date information about any affected area including population statistics, major road network conditions and current relief efforts. (95)

None of this is new. Since 1945, numerous studies have speculated how a dedicated UN mechanism might be established. Two secretaries-general, academics and military professionals have advocated the establishment of a permanent UN force. (96) What has not occurred in the last fifty years is the opportunity to make a major change in the UN during a Charter reform debate. Edward C. Luck, Director of the Center for Study of International Organizations, recommends "incremental reforms that don't force the members to make hard choices." (97) James Traub imagines "a different kind of institution, one that looks like a NATO with members with shared understanding of the world order and a shared willingness to confront threats to that order." He proposes a "Peace and Security Union" where "states have a responsibility to protect their own citizens, which in turn confers an obligation on the membership to intervene, at times through armed force, in the case of atrocities; extreme poverty and disease, which threaten the integrity of states, require a collective response." (98) Large-scale disasters should be included on this list requiring a multinational response.

A public health approach to disasters goes beyond immediate response. Public health depends on prevention and preparedness expenditures, If we examine failures to address technologies, such as lack of protective tsunami warning systems for the Indian Ocean, we see inequities that could be prevented by political awareness and leadership. Robin Harger, as former Southeast Asia representative for science and technology at the United Nations Educational, Scientific and Cultural Organization (UNESCO), suggests that the Indian Ocean tsunami death toll is a "tragic demonstration of the UN system's failure to get its priorities straight" with blame laid "directly at the feet of the highest officials in the UN system." (99)

One can conclude that in the shift to globalization, the emerging global culture has identified certain expectations. A global response to disasters, founded in public health and human rights, is one of those expectations of state capacity that must take precedence over politics. The frequency and severity of natural disasters in the past highlight real, indisputable but unrealized, expectations for a global response. Human security must be people-centric and not subject to the power of individual nation-states or their military forces. Whereas the U.S. military laudably contributes to global disasters, only ad hoc efforts have been directed to preparing forces and institutionalizing military sub-components.

The current UN reform movement provides a unique opportunity to bring purpose, vision and respect to the UN system. Many UN agencies already have outstanding managerial and logistical capability. However, a defined investment in a global disaster management system must provide that which is currently lacking the capacity to perform to expectations.

NOTES

(1) John C. Coatsworth, "Globalization, Growth, and Welfare in History," in Globalization: Culture and Education in the New Millennium, ed. Marcelo Suarez Orozco and Desire Baolian Qin-Hilliard (Berkeley, CA: University of California Press, 2004), 38-55.

(2) United Nations Institute for Disarmament Research, "Human Security" (report, UN), http://www.unidir.org/html/en/human_security.html.

(3) Ibid.

(4) J. J. Arnett, "The Psychology, of Globalization," American Psychologist 57 (2002): 774-83.

(5) YaleGlobal Online Magazine, "What is Globalization?" http://yaleglobal.yale.edtt/about/.

(6) Frederick M. Burkle, Jr., "Lessons Learnt and Future Expectations of Complex Emergencies," British Medical Journal 319 (1999): 422-426.

(7) Jacqueline Sims and Maureen E. Butter, "Gender Equity and Environmental Health" (working paper, Harvard Center for Population and Developmental Studies, June 2000): 2-3.

(8) Burkle (1999).

(9) Les Roberts and Charles-Antoine Hoffman, "Assessing the Impact of Humanitarian Assistance in the Health Sector," Emerging Themes in Epidemiology 1 (2004), http://www.ete-online.com/content/1/1/3.

(l0) Burkle (1999).

(11) Douglas W. Bettcher and Heather Wipfli, "Towards a More Sustainable Globalization: The Role of the Public Health Community," Journal of Epidemiology and Community Health 55 (2001): 617-18.

(12) Burkle (1999).

(13) Frederick M. Burkle, Jr. and George Rupp, "Hurricane Katrina: Disasters Keep Us Honest," Monday Developments 23 (26 September 2005): 5; Burkle (1999).

(14) Brian Urquhart, "Humanitarianism is not Enough," New York Review of Books (26 May 2005): 2629.

(15) "Daily press briefing" (brief, U.S. Department of State, Washington, DC: 6 September 2005), http://usinfo.state.gov/mena/Archive/2005/Sep/07-225374.html.

(16) "Water, sanitation key to disaster response, long-term development," U.S. Water News Online, http://www.uswaternews.com/archives/arcglobal/5watesani4.html.

(17) Jerry M. Spiegel, Ronald Labonte, and Aleck S. Ostry, "Understanding 'Globalization' as a Determinant of Health Determinants: A Critical Perspective," International Journal of Environmental Health 10 (2004): 360-67.

(18) Frederick M. Burkle, Jr., "Integrating International Responses to Complex Emergencies, Unconventional War, and Terrorism," Critical Care Medicine 33 (2005, supplement): S1-S6.

(19) Eric K. Noji, "Disasters: Introduction and State of the Art," Epidemiologic Reviews 27 (2005): 3-8.

(20) Burkle (1999).

(21) Bettcher and Wipfli (2001).

(22) Burkle (1999).

(23) A. Zwi and A. Ugalde, "Political Violence in the Third World: A Public Health Issue," Health Policy Planning 6 (1991): 203-217.

(24) Paul B. Spiegel, et al., "Developing Public Health Indicators in Complex Emergency Response," Prehospital and Disaster Medicine 16 (2001): 281-285.

(25) Agence France Presse, "The Year of Unnatural Disasters," http://web.lexis-nexis.com/universe/document?_m=c7a1108620e2 ac54e62f739a67a41831&_docnum=1&wchp=dGLbVtbzSkVb &_md5=96f8c185bb2e9c0db349224cd69f362a.

(26) Andrew T. Price-Smith, "Ghosts of Kigali: Infectious Disease as a Stressor on State Capacity" (paper presented at the annual meeting of the International Studies Association, Washington, DC: 19 February 1999).

(27) "Good Humanitarian Donorship" (report, Overseas Development Institute, June 2003), http://www.odi.org.uk/hpg/Good_humanitarian_donorship.htm.

(28) Douglas W. Bettcher and Kellev Lee, "Glossary on Globalization and Public Health," Journal of Epidemiology and Community Health 56 (2002): 8-17; Charlotte Benson and Edward J. Clay, "Disasters, Vulnerability and the Global Economy" in The Future Disaster Risk: Building Safer Cities, ed. A. Kreimer and M. Arnold (Washington, DC: World Bank, 2003), http://www.proventionconsortium.org/files/conference_papers/ bensonclay.pdf.

(29) Andrew T. Price-Smith, The Health of Nations: Infectious Disease, Environmental Change, and Their Effects on National Security and Development (Cambridge, Massachusetts: MIT Press, 2002), 23-27.

(30) Andrew T. Price-Smith, "Downward Spiral: HIV/AIDS, State Capacity, and Political Conflict in Zimbabwe," Peaceworks No. 53 (July 2004): 13-14.

(31) Ibid.

(32) Burkle (1999).

(33) Price-Smith (1999).

(34) Ibid; Price Smith (2004).

(35) Price-Smith (2002).

(36) Ibid.

(37) Deane Neubauer and Lynn Anne Mulrooney, "Globalization and Health: Round Two" (paper presented at the Pacific Global Health Conference, Honolulu, Hawaii: 15-17 June 2005), 3.

(38) L. Chen, et al., "Human Resources for Health: Overcoming the Crisis," Lancet 364 (27 November 2004): 1984-90.

(39) Caroline Hawley, "Brain drain puts strain on Iraq," BBC News, 28 July 2005, http://newsvote.bbc.uk/mpapps/pagetools/print/ news.bbc.co.uk/2/hi/middle-east/47262.

(40) Gareth Evans, "A More Secure World: Our Shared Responsibility," International Crisis Group (speech, Olaf Palme International Centre Seminar, Stockholm: 15 January, 2005).

(41) Charlotte Benson and Edward J. Clay, "Disasters, Vulnerability and the Global Economy" in The Future Disaster Risk: Building Safer Cities, ed. A. Kreimer and M. Arnold (Washington, DC: World Bank, 2003), http://www/proventionconsortium.org/files/ conference_papers/bensonclay.pdf.

(42) Noji

(43) Richard Ingham, "The Year of Unnatural Disasters," Independent Online (23 December 2005), http://www.iol.co.za/general/news/newsprint.php? art_id=qw1135312564372B251&sf=.

(44) Benson and Clay; Bettcher and Wipfli; Bettcber and Lee.

(45) Benson and Clay.

(46) Ibid.

(47) Colin Butler, "Entrapment: Global Ecological and/or Local Demographic? Reflections Upon Reading the BMJ's Six Billion Day Special Issue," Ecosystem Health 6 (2000): 171; Maurice King and Charles Elliott, "To the Point of Frace: A Martian View of the Hardian Taboo-the Silence that Surrounds Population Control," British Medical Journal 315 (1997): 1441-1443.

(48) Ibid.

(49) Benson and Clay (2003).

(50) World Report, "What will the new World Bank head do for global health?" Lancet 365 (28 May 2005): 1837-40.

(51) L. David Brown, et al., "Globalization, NGOs and Multi-sectoral Relations" (Working Paper no. 1, The Hauser Center for Non-Profit Organizations and The Kennedy School of Government, Harvard University, July 2000).

(52) Benson and Clay; Kelley Lee, "Globalization: What is it and how does it affect health?" Medical Journal of Australia 180 (2004): 156-158.

(53) Brown et al.

(54) D.P Fidler, "Globalization, International Law, and Emerging Infectious Diseases," Emerging Infectious Diseases 2 (1996): 77-84.

(55) Burkle (2005).

(56) D.L. Heymann and G. Rodier, "SARS: A Global Response to an International Threat," The Brown Journal of World Affairs (Winter/Spring 2004): 185-197.

(57) Ibid.

(58) Ibid.

(59) World Health Organization, "Epidemic and Pandemic Alert and Response" (report, WHO, 22 July 2005), http://www.who.int/csr/ihr/en/.

(60) World Health Organization, "World Health Assembly adopts new International Health Regulations" (report, WHO, 2005), http://www.who.int/mediacentre/news/releases/2005/pr_wha03/en/print.html.

(61) Angela Merianos and Malik Peiris, "International Health Regulations," Lancet 366 (8 October 2005): 1249-1251.

(62) Dean T. Jamison, Julio Frenk and Felicia Knaul, "International Collective Action in Health: Objectives, Functions, and Rationale," Lancet 351 (14 February, 1998): 514-517.

(63) World Health Organization, "WHO/State" (report, WHO), http://www.who.int/trade/glossary/story083/en/print.html.

(64) Ibid; Kelley Lee, "Shaping the Future of Global Health Cooperation: Where Can We Go From Here?" Lancet 351 (21 March 1998): 899-992; Bettcher and Lee.

(65) Burkle (2005).

(66) Ibid.

(67) Frederick M. Burkle, Jr., "Complex Emergencies and Military Capabilities," in From Civil Strife to Civil Society, ed. William Maley, Charles Sampford and Ramesh Thakur (New York: United Nations University Press, 2003), 96-108.

(68) Steven Hansch, e-mail personal communication to author, 4 August 2005.

(69) Lara Jakes Jordan, "Report: Government-Wide Katrina Failings," Associated Press, 2006, http://news.yahoo.com/s/ap/2006021/ap_on_g_co/ katrina_congress&printer=1;_ylt=Aj8.

(70) Gary Cecchine, Michael A. Wermuth, Roger C. Molander, et al., "Triage for Civil Support," (report, National Defense Research Institute and RAND Health, Arlington, VA: 2004).

(71) Ibid; Randall Culpepper and Patrick Kelley, "DOD-Global Emerging Infectious Surveillance and Response System," Navy Medicine 93 (September-October 2002): 10-14.

(72) Robert D. Kaplan, "Next: A War Against Nature," New York Times, 12 October 2005.

(73) Kenny Cluck, "A Military Role in Disaster Relief," New York Times, 19 October 2005.

(74) Ibid.

(75) U.S. Department of Defense, "Military Support for Stability, Security, Transition and Reconstruction (SSTR) Operations" (directive no. 3000.05, DOD, Washington, DC: 28 November 2005), http://www.dtic.mil/whs/directives.

(76) Ashton B. Carter, "The Perils of Complacency: Adapting U.S. Defense to Future Needs" (paper presented at the 41s' Annual Conference of the International Institute for Strategic Studies, San Diego, CA: 9 September 1999).

(77) Sphere Project, Humanitarian Charter and Minimum Standards in Disaster Response (Oxford: OXFAM Publishing, 2004).

(78) Burkle (2005).

(79) Naomi Klein, "The Rise of Disaster Capitalism," Lookout (2 May 2005).

(80) Office of the Spokesman, U.S. Department of State, "President Issues Directive to Improve the United States' Capacity to Manage Reconstruction and Stabilization Efforts" (fact sheet, Washington, DC: 14 December 2005).

(81) Frederick M. Burkle, Jr. and Eric K. Noji, "Health and Politics in the 2003 War with Iraq: Lessons Learned," Lancet 364 (9 October 2004): 1371-75; Frederick M. Burkle, Jr., Bradley A. Woodruff and Eric K. Noji, "Lessons and Controversies: Planning and Executing Immediate Relief in the Aftermath of the War in Iraq," Third World Quarterly 26 (2005): 797-814.

(82) Kenneth Roth, "Setting the Standard: Justifying Humanitarian Intervention," Harvard International Review XXVI (Spring 2004): 58-62.

(83) Human Security Center, "Human Security Report" (report, HSC, 2005), http://www.humansecurityreport.info/HSR2005/What_is_HS.pdf.

(84) Ibid.

(85) Ibid.

(86) Judith Asher, "Right to Health: A Resource Manual for NGOs" (manual, American Association for the Advancement of Science, Washington, DC: 2004), 75.

(87) Ilona Kickbusch, "Influence and Opportunity: Reflections on the U.S. Role in Global Public Health," Health Affairs 21, no. 6 (November/December 2002): 131-141.

(88) Tasos Papadimitriou, "A Radical Vision for the Future of the UN," Global Policy Forum (24 October 2004), http://www.glohalpolicy.org/ security/re form/cluster1/2004/1024radical.htm.

(89) Ibid.

(90) H. Peter Langille, "Conflict Prevention: Options for Rapid Deployment and UN Standing Forces," Global Policy Forum (1999), http://www.globalpolicy.org/security/peacekpg/reform/canada2.htm; Kickbusch (2002).

(91) Ibid.

(92) Langille (1999).

(93) United Nations Office for the Coordinator of Humanitarian Affairs (OCHA), "Guidelines on the Use of Military and Civil Defense Assets to Support UN Humanitarian Activities in Complex Emergencies" (report, OCHA, Washington, DC: March 2003), http://ochaonline.un.org/DocView.asp?DocID=426; A.W. Gunder, "The Utility of Expanding the United Nations Permanent Military Force" (report, Command and Staff College, Quantico, VA: 18 April 1995), http://www.globalsecurity.org/military/library/report/1995/GAW.htm.

(94) Ibid.

(95) OCHA Online, "IASC Endorsed Terms Of Reference For A Humanitarian Information Centre," http://ochaonline.un.org/webpage.asp?page=710.

(96) Langille (1999).

(97) James Traub, "The Un-U.N," New York Times Sunday Magazine, 11 September 2005.

(98) Ibid.

(99) Robin Harger, "Wave of Ignorance," Al-Abram Weekly Online Journal 724 (6-12 January 2005), http://weekly.ahram.org.eg/print/2005/724/in1.htm.
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Title Annotation:RELIEF and RESPONSE
Author:Burkle, Frederick M., Jr.
Publication:Journal of International Affairs
Date:Mar 22, 2006
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