Social chaos—the ignored tragedy in global health

January 2014 TheLancet; Universal health coverage, the Millennium Development Goals, non-communicable diseases, health system strengthening, the social determinants of health, and even the right to the highest attainable standard of health. These issues are fiercely discussed. They top the agendas of most global institutions concerned with health. Perfectly rational reports are published by experts explaining how each priority can be achieved or addressed. Resolutions are passed at World Health Assemblies. Success is celebrated at UN General Assemblies. Evidence is synthesised into guidelines that scientists say can reap large rewards if translated into practice. Heads of UN agencies, development partners, research funders, and health foundations speak optimistically about progress. And yet almost the entire field that is global health today has built an echo chamber for debate that is hermetically sealed from the political reality that faces billions of people worldwide. That reality is social chaos: the disruption, disorder, disorganisation, and decay of civil society and its institutions. Social chaos erodes societies, destroys communities, eviscerates health systems, and eliminates any remaining vestiges of hope individuals might have for better lives. And yet social chaos is nowhere on the global health agenda. It is systematically ignored, marginalised, or censored.

Three categories of social chaos deserve greater consideration. First, the 1·5 billion people who live in countries affected by violent conflict. Take the most serious current examples. In 2014, 531 million people in seven countries live in settings of war or violence that killed more than 1000 people during the preceding year. South Sudan, the Central African Republic, Iraq, Syria, Mexico, Pakistan, and Nigeria are today the most severe zones for armed conflict. Each nation, although high on the international news agenda, receives little coordinated high-level political attention from global health leaders. No national integrated efforts between agencies to protect civilians from violence or harm, no regional mobilisation of resources to shield the most vulnerable, no global convening of parties in conflict to address the urgent needs of populations most at risk. WHO says it is helping to provide essential services to support the management of common illnesses in many of these settings—eg, in South Sudan. But even WHO acknowledges that too few partners are working on the ground where help is urgently needed. Uppsala University’s Conflict Data Program, the most authoritative source of information on armed conflict, concluded last year that the international community has done far too little to respond to these conflicts. Internally displaced persons and refugees make up a second category of those affected by social chaos. UNHCR estimates that 28·8 million people are internally displaced in the world today, a figure that is increasing. There are over 10 million refugees. And around 12 million people are stateless. A third category of social chaos is “fragility”—36 countries (most in sub-Saharan Africa) that are classified by the World Bank as having either UN peacekeeping missions or severely suboptimal economic and public sector management, policies, or institutions.

These matters of armed conflict, internal displacement, and fragile situations are never seriously discussed in global health fora. No UN head of agency has made the security dimensions of health a headline issue of their leadership. The closest their predecessors have come is to talk about human security. But although that idea reached its apotheosis in 2003, with publication of Sadako Ogata’s and Amartya Sen’s Commission on Human Security, today the concept is no longer an important concern for policy makers. This omission needs correction. Social chaos should be a more central concern for global health. Actions are very clear—protecting people in situations of violent conflict, supporting the safety and security of people on the move, establishing mechanisms (and funding) to support people living in post-conflict settings, and making the quality of national institutions a more urgent concern. Until social chaos is made a priority by leaders in global health, all hopes of advancing human wellbeing will fall well below expectations. As Ogata and Sen wrote in 2003, “The task demands leadership and vision as well as commitment from the world community.” As events in Syria, Iraq, the Central African Republic, and South Sudan show all too clearly, world health leaders have failed this test.

 

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