POLICY AND PRACTICE
Security, insecurity and health
Sécurité, insécurité et santé
Seguridad, inseguridad y salud
Robin Coupland
International Committee of the Red Cross, 19 avenue de la Paix, CH-1202 Geneva, Switzerland. Correspondence to Robin Coupland (email: rcoupland@icrc.org)
ABSTRACT
An examination of the nexus of security, insecurity and health shows that security is a prerequisite for health. The many and varied ways that armed violence - including threats of armed violence - can affect people's health can be documented by formal studies; however, valuable data also exist in other reports, such as media reports. The health community needs to recognize that people's insecurity is a massive global health issue. The foreign policies of donor governments should incorporate recognition that documentation, analysis and publication of data describing the impact of insecurity on people's health can lead to the creation of policies to enhance people's security.
RÉSUMÉ
L'examen des interactions entre sécurité, insécurité et santé montre que la sécurité est un préalable à la santé. Les manières, nombreuses et variées, dont la violence armée, y compris les menaces de violence armée, peuvent nuire à la santé des personnes peuvent être documentées par des études formelles. Néanmoins, d'autres rapports peuvent fournir des données utiles, notamment les rapports dressés par les médias. La communauté sanitaire doit reconnaître que l'insécurité pour les personnes est une question de santé publique de très grande ampleur. Les politiques étrangères des gouvernements donateurs doivent intégrer que le rassemblement, l'analyse et la publication de données décrivant l'impact de l'insécurité sur la santé des personnes peuvent conduire à la proposition de politiques pour améliorer leur sécurité.
RESUMEN
El análisis de las relaciones entre la seguridad, la inseguridad y la salud muestra que la seguridad es un requisito previo para la salud. Es posible documentar mediante estudios formales las muchas y diversas formas en que la violencia armada -incluidas las amenazas de violencia armada- pueden afectar a la salud de las personas; sin embargo, se pueden encontrar también datos valiosos en otros ámbitos, por ejemplo en noticias publicadas en los medios. La comunidad sanitaria tiene que reconocer que la inseguridad de la población constituye un problema sanitario mundial masivo. En las políticas exteriores de los gobiernos donantes se debería reconocer que la documentación, el análisis y la publicación de los datos que demuestran las repercusiones de la inseguridad en la salud de la población pueden favorecer el desarrollo de políticas que mejoren la seguridad de la gente.
Introduction
In contexts of poor security, public health interventions and the delivery of health care to the individual are more difficult to perform and less likely to succeed than in contexts of security. Violence - including the threat of violence - in such contexts results in injury, death, psychological harm, impaired development or deprivation. Insecurity, therefore, potentially has a double impact on people's lives and well-being; this is the reality of everyday life for many millions of people. The nexus of security, insecurity and health is as complex as it is important. In a given context, responsibility for what happens at this nexus falls to multiple actors, including ministries responsible for health, defence and internal affairs; the overriding influence, especially on security, may even be the foreign policy of other countries.
Levels of security
People's security
People's security has been described as:
"... a basic value because it is an essential requirement, or condition, of a successful and fulfilling existence: it liberates people (both physically and mentally) to get on with the business of building their lives without undue fear of those around them ... It is also peace of mind: liberation from the anxiety and apprehension associated with fear of those who are in a position to harm us."1
This description of personal security runs parallel to the "narrow" concept of human security described in the Human security report 2005: "it is about protecting individuals and communities from any form of political violence".2 Given that the definition of health encompasses a state of complete physical, mental and social well-being, it is both logical and intuitive that people's security, whether viewed collectively or at an individual level, is necessary but not sufficient for their health.3
This observation is not new. In 1651, Thomas Hobbes wrote that without security,
"... there is no place for industry... no arts; no letters; no society; and which is worst of all, continual fear, and danger of violent death; and the life of man, solitary, poor, nasty, brutish and short."4
He argued for collective security arrangements to ensure the security of the individual, but to which the individual had little option but to consent. John Locke was the first political philosopher to argue for government by popular consent as a means to achieve collective security. In 1690, he wrote about security and well-being as a function of government; in addition, he integrated this with the notion that humans had rights:
"Men, by nature all free, equal and independent, no one can be put out of this estate and subjected to the political power of another without his own consent. The only way whereby anyone divests himself of his natural liberty and puts on the bonds of civil society is by agreeing with other men to join and unite into a community for their comfortable, safe and peaceable living one among another, in a secure enjoyment of their properties..."5
The dichotomy of opinion of these two authors relates not to the need for people's security but to how it might be achieved; a dichotomy that still finds resonance today.
National security
National security is one route to ensuring people's security; but there is ample evidence that national security is no guarantee for the security of all the people living in a country. There is therefore potential conflict between the core political value of national security and the core moral value of people's security. The introduction of the notion of human security by the United Nations Development Programme (UNDP) in its Human development report 1994, permitted convergent thinking about people's security and human rights.6 In 2001, this emerging interest in human security reflected a willingness to integrate concerns for people's security and its link to health within international political discourse.3
International security
The primary purpose of the United Nations is to hold responsibility for a third level of security: international or global peace and security. International security depends on the system of national governments, and means peace, order and lawfulness within the society of countries. Taken together with a notion of people's security, it means the advancement of civilization and, above all, health. Nevertheless, in article 2.7, the United Nations Charter acknowledges the tension between people's security and national security. While national security may be subordinated to international security, it is only when people's insecurity within a country is of such magnitude that it poses a threat to international security that intervention by other countries using force can be justified. This is also a notion that has gained higher prominence in recent years.7
Creating insecurity and ensuring security
Armed violence
Security is a prerequisite for health and insecurity is bad for health. These are politically inconvenient truths that are all too evident. Sitting behind these inconvenient truths and all the above considerations of security and insecurity is one basic and uncomfortable fact: this is all about weapons and how they are used. Humans have and always have had an extraordinary ability to find the technical means to overcome their physical and psychological limits when dealing with an adversary. This is central to human affairs today. Viewed in these terms, the stuff of politics, defence and law enforcement is armed violence, national governments' monopoly on armed violence and the potential for it, agreements to control armed violence, and ultimately decisions about who inflicts armed violence on whom, where and how. Possessing a potential for armed violence and even committing acts of armed violence may ensure security at individual, national and international levels. At the same time, security at all these levels can be destroyed by armed violence. From a historical perspective, armed violence has shaped the political world and the structures that should serve to ensure our security.8 Furthermore, our security and the insecurity of others are obviously issues that generate keen interest - because ultimately they relate to our own physical, mental and social well-being. Why else does armed violence feature so prominently in the daily world news?
The health effects of armed violence
The direct effects of armed violence (these being ballistic trauma and its sequelae) can only be negative in terms of the impact on health of the individual victims. The indirect effects include fear, coercion, displacement and deprivation of essentials such as clean drinking-water, food and health care. A person wounded in a context of poor security resulting from widespread armed violence suffers the ballistic trauma and the indirect effects brought by difficulty in accessing medical care. However, the indirect effects can also be positive. A police officer may legitimately shoot a violent criminal in self-defence; this may benefit society as a whole even though the direct impact of the act on the health of the criminal is negative. The same is true of armed violence for the purpose of defending a country might ensure the security - and so the health - of citizens.
Whether security or insecurity prevails depends on the outcome of a critical balance with, on one hand, acts of armed violence, the potential and threat of armed violence and its control and, on the other hand, its overall effects. Further arguments flow from this. Massive investment in national security does not translate necessarily into people's security, especially when the apparatus for national security is used against those same people. In this case, armed violence has an additional impact on health owing to under-resourcing of health services (because "defence" has priority). Is this not a familiar story? Is it correct to refer always to "developing countries" or should reference also be made sometimes to "countries that are not developing because the people are insecure and as a result unhealthy"?
Common sense and ample evidence can be rallied in support of so much theory. This author witnessed a fight between two rival groups of football fans in the emergency department of a London teaching hospital. One of the combatants produced a knife and threatened a member of staff. No patient - football fan or not - received any treatment in that emergency department for three hours. Even the best health-care facility can be rendered ineffective in the face of a relatively minor security incident. Any military doctor knows the factor that determines whether or how you are treated if wounded on a battlefield: it is whether your side wins. The plight of civilians wounded in armed conflict is so miserable in many situations precisely because, first, they are wounded; second, they are in an insecure environment; and third, they do not have an armed force that imposes the security necessary to ensure their treatment.9 In other words, if a person's life is in danger because of a poor security environment, competent health care is unlikely to be received in that environment. For hard evidence of the wider impact of poor security on health, one need look no further than a comprehensive study on mortality in the Democratic Republic of the Congo.10 Such a study forces us to recognize the links between security, insecurity and health. It should also force us to recognize that, in a given context, the relationship between successful implementation of programmes for the prevention and treatment of human immunodeficiency virus (HIV) or malaria and the number of people who are threatened, wounded or killed by firearms has not yet been examined.11
The role of public health in insecure contexts
At a global level, what is the role for "public health" in people's security when it would seem that people's security lies in the hands of politicians, soldiers, police and diplomats? While the question implies collaboration between ministries of health and ministries of foreign affairs, it is not obvious on what they might collaborate. It is proposed here that documentation of the health impact of people's insecurity must be given a higher priority on the global health agenda, since it is possibly the most important thing that public health can do to improve health in insecure contexts.
Studies on people's security
Documenting the impact of insecurity on health goes much further than enumerating how many people are killed or injured in a given context of violence (although such data alone may be an accurate indicator of the degree of people's insecurity). Investigation and publication of the health impact of people's insecurity using a variety of general health indicators constitute critical elements of the creation of proposals for how to improve people's security. There are many examples of such proposals, including those relating to injuries from anti-personnel landmines,12 civilian deaths and injuries from cluster bombs,13 the impact on civilians of the availability of small arms,14 weapons' injuries following departures of peace-keepers,15 mortality among people displaced by conflict,16 the impact on civilians of the 1999 conflict in Kosovo,17 massacres,18 the prevalence of war-related sexual violence in Sierra Leone,19 violence and mortality in Darfur, Sudan,20 and the number of people killed in Iraq since 2003.21 These and many more studies show that credible data can be gathered under difficult conditions. With respect to ameliorating people's security, the authors either propose solutions or assume that the solutions are so obvious (for example, that governments and armed forces respect international humanitarian law) that the proposals are left unstated. Whichever the case, there are always clear implications that the remedy is in the hands of politicians and diplomats. The value of these studies is that they serve to inform and to create a burden of responsibility upon those who are usually responsible for national or international security but who should also be responsible for people's security. It could be argued that without data, no burden of responsibility is created and without the burden of responsibility, policy in favour of people's security is not established.
While policy-makers frequently have difficulty comprehending science, the "data-to-policy" process, which includes creating a burden of responsibility, is an important mechanism for promoting people's security. The data generated by the kind of studies cited above may lead to the creation of treaties and policies regarding development, production, transfer and use of weapons. They may provide evidence of war crimes or crimes against humanity. By necessity, field-level interventions such as clearance of mines or explosive remnants of war and firearm-destruction programmes together with a host of remedial health interventions also feed off from such studies. In other words, the gathering, interpretation and publication of data describing the impact of insecurity on people’s lives and well-being is an important part of a process that ultimately ensures the security that is a prerequisite to health.
Alternative sources of data on people's insecurity
But then other questions arise. Is the only means to document people's insecurity the kind of formal study cited above? Is it always necessary for health professionals to be the observers and documenters of the impact of insecurity on people's lives and well-being in precisely those situations where it may be difficult and dangerous to gather data? Are there alternative sources of data that can be analysed and published to the same effect? Progress is being made towards translating qualitative data from media and other reports into meaningful quantitative data that in turn can generate an accurate and objective picture of the nature and effects of armed violence in a given context.11,22,23 Such data being collected for other purposes may be incomplete and may contain inaccuracies; however, short of formal surveys, it is the best source available. It is also the only source that is updated daily and, like it or not, policy - and especially foreign policy - is already built on such reports. Using a method that translates reports, including media reports, of events of armed violence into meaningful data provides an opportunity for a kind of surveillance by proxy of people's insecurity in numerous contexts. It can work for any given context, provided that written reports of individual events of armed violence exist.11
Collaboration between the health community and policy-makers
Given the arguments and observations described above, it could even be argued that people's insecurity is the single most important global health issue. If one accepts this premise, it means that those concerned with international health issues, including ministries of health, cannot simply focus on the promotion of health. They must also focus on the health impact of insecurity; this implies convincing ministries of foreign affairs of the importance of gathering, analysing and presenting data pertaining to the health implications of insecurity. Those who make the foreign policies of donor countries should consider augmenting the resources dedicated to these activities because they are a critical element in the promotion of people's security. Academic institutions should also promote the issue of the health impact of people's insecurity as a legitimate and valuable field of enquiry. Furthermore, there are potentially ample raw data pertaining to people's insecurity in the form of written reports, including media reports, which have not yet been analysed. These also should be collected, analysed and published in a coherent manner and brought to the attention of policy-makers in compelling terms.
Conclusion
The nexus of security, insecurity and health must take centre stage in foreign policy thinking. People's security is a prerequisite for a peaceable, constructive and collective existence in which individuals have the best chance to live in a state of complete physical, mental and social well-being. People's insecurity is a massive global health issue and, at the end of the day, comes down to armed violence and its effects, both direct and indirect. The health impact of insecurity can be documented and used to change security policies that in turn can have a powerful positive impact on health. The required security can be and has been achieved by interplay of international, national and personal security measures, many of which constitute national obligations under international law. The new thinking about people's security - or human security - must be promulgated in these terms by the international health community. While donor governments make funds available for programmes that promote health and at the same time for programmes that promote people's security, funds should also be made available for investigating the insecurity that may be the reason why people are unhealthy or why health programmes cannot be implemented. Recognizing that security for all is a prerequisite for health for all implies closer collaboration between the health community and ministries of foreign affairs. 
Competing interests: none declared.
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(Submitted: 2 October 2006 Final revised version received: 28 November 2006 Accepted: 4 December 2006)