Open access peer-reviewed chapter
Abstract
The present era is defined by a confluence of crises and a degree of global interconnectedness without historic precedent. A Toxic Triumvirate of climate change, conflict, and contagion have synergistically functioned to cast our collective, global public health into extreme jeopardy. The COVID-19 pandemic, War in Ukraine, and advancing climactic catastrophe have devastated our world: destabilizing nations, severing vital supply lines, and fracturing indispensable health infrastructure. All the while, the threat of nuclear war and the risk of devastating pandemic from emerging infectious disease (EID) grow in the unchecked wounds of low- and middle-income countries (LMIC). Nations of the Global South have been rendered super-vulnerable to the Toxic Triumvirate’s effects through historic global inequity and chronically anemic international support. These “developing” nations are subject to unsustainable extremes of risk secondary to a compounding of hazard. This amplified risk is transmitted through our world via vibrant arteries of commerce that intimately connect us. Our world’s collective health is in a state of jeopardy demanding a vigorous, equitable, and cooperative international response. To chart a course toward a safe future for our children, we must rectify the profound inequities that present our world’s shared Achilles’ heel and invest in the sustainable development of LMIC.
Keywords
- public health
- climate change
- vaccine inequality
- pandemic
- infectious disease
- climate change
- inequality
- transfer of hazard
1. Introduction
The needle ticks 100 seconds to Midnight. The atomic scientist’s hands shake as she advanced the 2020-2022 Doomsday Clock closer to Armageddon than it had ever been. The Bulletin of Atomic Scientists, established in 1945 by Albert Einstein and Manhattan Project scientists, have watched in horror as crises have grown to become confluent, mounting a compounded risk to our collective global health that is without historical precedent.
Our international body, intimately, and vibrantly connected through coursing arteries of trade and travel, has become terminally ill. A poison of inequity taints our shared bloodstream, crippling the vital international and national organ systems it touches. Disease, violence, and climatic cataclysm have battered and deluged our world with unprecedented suffering. Beneath the bullets and bombs, the temperature and water level continue to rise, and the risk of lethal pandemic brews within the unchecked wounds of the Global South.
The upper extremities in the Global North, finding themselves circumstantially above a rising water level, have attempted to further secure themselves against catastrophe. Low- and middle-income countries (LMIC), who very literally find themselves underwater, are left to struggle for survival without sustainable and effective international support. Vital organ systems of infrastructure, indispensable to curtail our ever-advancing risk, have wasted from chronically anemic funding streams, now lying unable to maintain global homeostasis. As organs fail, our shared arterial supply lines lose pressure, and the vulnerable tissues of the Global South, deprived of support and oxygen, begin to necrose. Below the water line, impoverished and traumatized communities become a gangrenous point of entry for fatal superinfection capable of disseminating through our world’s circulatory system like wildfire.
At our body’s beating heart, nations stand united to treat these life-threatening wounds and protect our collective health. However, their work has been stymied and paralyzed by the reluctance of wealthy, non-LMIC nations of the Global North to invest in the sustainable development and protection of the Global South. In our increasingly interconnected world, the Global North’s historic strategy of self-protection and investment at the expense of LMIC has become a fool’s errand [1, 2, 3, 4].
1.1 An existential and ethical crisis
The triumvirate specters of climate change, conflict and contagion haphazardly sway about our heads like Damocles’ Blades. Bound in strengthened communion by morally decayed sinews of inequity, these Toxic Triumvirate have grown to present the human species with the greatest existential dilemma of its relatively brief history.
Climate change is advancing at a rapid pace and its effects have become of cataclysmic severity. Climactic upheaval ranging from sweeping fires across Europe to catastrophic floods in Africa and Southeast Asia have devastated and destabilized nations across the globe. Amidst catastrophe and resource limitation, old fault lines of conflict are becoming active, and new flashpoints are opening across the world at a dangerous and intensifying pace. The War in Ukraine has paralyzed international trade and economic growth in a world still attempting to recover from an ongoing SARS-CoV-2 (COVID-19) pandemic. Humanitarian catastrophes cripple the Global South amidst a maelstrom of conflict and climatic cataclysm. Within these concentrations of human suffering and misery, the specter of zoonotic pandemic from emerging infectious disease (EID) gathers strength. In our interconnected world, a single spark struck in a war-torn, impoverished, and destabilized corner of the globe has the potential to start an international blaze. United Nations (UN) Secretary General (SG) Antonio Guterres opened the 2022 77th Session of the United Nations General Assembly (UNGA) noting, “We are meeting during a time of great peril.” The theme of the assembly was designated: A Watershed Moment: Transformative Solutions to Interlocking Challenges. The meeting was a call for international cooperation in facing the uniquely interrelated crises of climate change, war, and COVID-19, as well as the catastrophic humanitarian crises emerging in their midst.
The field of public health is entering an era of challenge and demand that is without historical precedent. The triune wraiths of contagion, climate change, and conflict, each representing an existential threat in their own right, present a confluent crisis demanding an urgent and vigorous international response.
In this chapter, I will advocate for an approach to improving and preserving global health security that leverages the power of international solidarity and sustainable development to decrease our shared risk and to help ensure a safe and habitable world for our children. The vice of inequity has shifted from being a neglected ethical responsibility to an existential imperative. The present era demands that humanity reconcile the disparities that have so marred our past, or risk succumbing to the bitter fruit of our pride & prejudice [5, 6, 7, 8, 9].
2. Inequality: a lethal intoxicant
On December 10, 1948, the UNGA signed the United Declaration of Human Rights (UDHR) into inception, representing an important, global ethical advance. However, while nations proclaim support for the UDHR, basic rights remain unprotected across the world.
We live in an interconnected era where health and risk have become socialized and globally shared. The hazardous conditions presented by inequality anywhere reduce the safety of people everywhere. This is exemplified by the inequitable response to the COVID-19 pandemic, where critical under vaccination within the Global South has facilitated the development and circulation of COVID-19 variants that have wreaked havoc across wealthy and impoverished nations alike.
Inequity is fundamental to the persistence of COVID-19 and represents an increasingly exposed Achilles’ heel for the continued recurrence of internationally paralytic pandemics. The international inequity and impoverishment that cripples nations of the Global South is not a natural phenomenon. Current global inequality has been created and maintained by specific national and international interventions, and it can be undone just the same. We enter an era where the reconciliation of international inequities must be expediently and sustainably accomplished if we are to meaningfully reduce our historic level of international risk [10, 11, 12].
2.1 One health and one risk
The concept of One Health emerged as a solemn acknowledgment of the complexity of human health and the myriad of critical socioeconomic and environmental factors that influence it.
In 2021, the World Health Organization (WHO) formed the One Health High-Level Expert Panel (OHHLEP) to advise a multidisciplinary approach to address climate change as well as disparities in global infrastructure, agriculture, and environmental resilience.
These critical inequities pose a threat to global health with their combined effect noted to increase conditions favorable for pandemic pathogen introduction and dissemination, hereby referred to as
2.2 The challenge before us
In this age of unprecedented and complex risk to global health, the safety of our international community will rest upon cooperative, responsive, and effective international leadership. This is an area of urgent and utmost need. Global voices including Antonio Guterres and Pope Francis have sharply criticized the failure of current national and international leadership amidst COVID-19, the War in Ukraine, and climate change.
The COVID-19 pandemic has demonstrated that one of the largest contributors of international impotence is a lack of intergovernmental coordination and a poverty of financial commitment by wealthy nations. Our current lack of intact and effective health systems in the Global South will result in critical delay of pandemic detection. The risk wrought by this disparity in health infrastructure is compounded by critical inequities in other fundamental domains including: financial resources, education, food security, essential water/sanitation/hygiene, and energy infrastructure.
The extreme concentrations of hazard and risk present in LMIC of the Global South is transmitted and disemminated among our global community through a common international circulatory system. If we are to safely navigate this perilous era, we will need to repair the wounds of the past and equip nations of the Global South with the critical infrastructure they will require to reduce the currently unsustainable levels of global risk [9, 15, 16].
2.3 Vital organs: five fundamental equalities
The benefit of even a perfect medicine is precluded in the absence of vital organs. Likewise, sustained development can only take root in the setting of functional, essential national infrastructure. Below I will review five essential equalities that are prerequisite to the sustainable and empowered global development that must be expeditiously accomplished if we are to mitigate our present level of risk [9, 15, 16].
2.3.1 Global wealth equality
Global wealth inequality has not changed in over a century. Wealth and finance, essential for the development of any nation, are home to some of our world’s most egregious disparities. The Internal Monetary Fund (IMF) published its 2022 World Inequality Report (WIR) decrying severe disparities that developmentally stymie the Global South. The report indicated that approximately 10% of the world’s population is responsible for 76% of global wealth, 52% of global income, and 48% of global carbon emissions. The poorest half of our global community was found to earn only 8.5% of world wealth. Despite our stated international commitment to reconciling fundamental disparities in wealth, the inequities that cripple the Global South remain as stark as observed in 1920.
October 10, 2022: The IMF and World Bank Group (WBG) began their annual meeting in Washington, D.C. to discuss the urgent issues of global economic downturn, poverty eradication, and economic development. The summative conclusions reported as the meeting progressed are grim. The twin crises of COVID-19 and the War in Ukraine have devastated the global economy resulting in skyrocketing inflation. In the wake of systemic, economic incapacitation, national GDP has been in free-fall affecting nations of the Global South disproportionately. Nations of the Global North have also been severely impacted, with the IMF forecasting diminishing national growth and possible, global recession into 2023 [15, 17].
2.3.2 Universal energy infrastructure
Energy has been essential for human survival from time immemorable, but it comes at a price. Western European countries have experienced significant rises in energy and cost of living as international energy infrastructure has been critically disrupted by the conflict in Ukraine.
The Global South pays a different price. Inhaled air pollutants like combustion byproducts represent a leading cause of global morbidity and mortality estimated to be responsible for more than 10 million excess deaths each year. This suffering is disproportionately concentrated in LMIC whose infrastructural development and energy transition have been curtailed by international intervention and negligence.
The 1970s brought an American-led end to the Post-WWII Breton Woods International Economic System that had previously constrained the corporate flow of capital. In its place, a neoliberal, political-economic policy permitting ruthless corporate expansion and exploitation further deepened our global inequities. The Global North, having stumbled through the perils of industrial revolution at catastrophic cost to domestic labor workforce and the international poor, begin to power a transition to improved forms of energy by exporting upscaled, dangerous, and crude manufacturing processes to LMIC. The pressure to exploit LMIC as regions of manufacture due to lax labor and environmental regulation led to a critical
Currently, approximately 50% of the world’s population lack access to improved energy infrastructure and are dependent on solid fuels, which result in substantial increases in exposure to combustion’s mediators of disease.
When energy infrastructure fails, cataclysm can become a catastrophe. Climate change and conflict have taken devastating tolls on the infrastructural integrity of nations across the world. Ukraine, following Russian shelling in early October, had lost 40% of its energy infrastructure resulting in sweeping outages and their pathologic sequela such as loss of access to clean drinking water and failure of sanitation resources [9, 18, 19].
2.3.3 Universal food security
We have lost progress in the fight against global hunger. In 2022 the World Food Programme (WFP) declared a global food crisis, noting this to be a year of unprecedented food insecurity. The UN/WHO 2022 State of Food Security and Nutrition in the World Report described a deepening inequity in access to food that is heavily impacting the Global South. As of the late 2022 writing of this chapter, the African Horn and Eastern Africa are experiencing drought-induced famine with affected nations demonstrating concerning rises in child malnutrition. Last year in flood-stricken Nigeria, the WFP announced that it would have to reduce food support by 50% due to funding limitations. At a time when international need has peaked, the anemic support from the Global North that has become the historic norm must change. Across the world, malnutrition is acting to weaken immune systems in the regions where outbreak risk is the highest. To leave nations to succumb beneath conflict, climactic catastrophe, and hunger represents both a reckless jeopardization of our collective health and an absysmal ethical failure [20, 21].
2.3.4 Universal water, sanitation, and hygiene (WASH) infrastructure
The WHO and United Nations International Children’s Fund (UNICEF) Joint Monitoring Program (JMP) has been monitoring global access to water, sanitation, and hygiene (WASH) infrastructure since its inception in 1990. Currently, 2.1 billion people lack access to safe drinking water and 4.5 billion people lack sanitation. Approximately 800 children die from preventable diarrheal illness every day because of this. Nearly all of the nations still requiring WASH infrastructure are located on the African continent. The lack of WASH infrastructure affects much more than health. Clean water and sanitation are essential for the development of children, economies, and nations. As such, this inequity represents a key barrier to the sustainable global development we will need to improve our collective safety. The UNICEF 2016-2030 WASH framework is designed to rectify this inequity with the goal of achieving universal and equitable access to safe water, sanitation, and hygiene by 2030. However, as with many efforts toward equity, the UNICEF WASH initiative has been critically frustrated by chronically anemic financial support from wealthy nations of the Global North [22, 23].
2.3.5 Universal national health infrastructure
In early October 2022, 70 children passed from acute kidney failure in the Gambia. The culprit was found to be tainted cough syrup shipped from an Indian pharmaceutical company. In the late 2022 final drafting of this chapter, more than 130 children were reported to have passed from acute kidney illness secondary to cough syrup in Indonesia and the case count is rising.
Vulnerable children are said to be “an infection away from catastrophe” and not even their medicine is safe. Global inequity in health infrastructure takes an immeasurable toll on LMIC. Preventable diseases of poverty shackle the economies of the Global South, while waves of outbreak from Ebola to COVID batter nations like storm surges.
Global equality in health infrastructure is the cornerstone of our defense against pandemic. In order for deadly pathogen to be effectively identified and contained within the region of introduction, there must be essential national health infrastructure in place. In its absence, such as in the 2014 Ebola Epidemic, outbreaks are able to spread unmitigated and undetected like wildfire. Functional national health infrastructure is also imperative to the control of the preventable diseases of poverty that disproportionately take their toll on the youngest generations—crippling the capacity of affected nations to develop.
Recent research on the health infrastructure of LMIC has articulated three consistent features found in health systems of the Global South: insufficient resources, weak state effective capacity, and high burden of disease. As their internal capability for development has been critically impaired, nations of the Global South will require significant and expedient international investment to kick-start the establishment of functional and sustainable civil infrastructure and healthcare systems. Universal health infrastructure will be fundamental to our global safety as effective, local pandemic preparedness and disaster response will require organized and decisive national action in order to control fires at their source [24, 25, 26, 27, 28].
2.4 A road to sustainable development
The reviewed dilemmas of inequality represent recognized global emergencies to which the UN, WHO, and other international actors have responded. In the year 2000, the Millennium Development Goals (MDG) were designated by the UN. These eight goals represented key global disparities to be addressed through an internationally cooperative response.
The Sustainable Development Goals (SDG) were designated in 2015, immediately in succession of the MDG. The SDG represent an enhanced set of aims incorporating lessons learned from the prior MDG and distinguish themselves in their focus on sustainability. Chronic inequity has rendered nations of the Global South uniquely disempowered to affect their own development with many prior interventions in the Global South having been reactive, superficial, and unsustainable. Nations of the Global South must be released from poverty, debt, disease and violence, and empowered to develop and build the capacity necessary to weather the storms to come. In our present world, the health of our global community depends on the health of its constituents. The watershed of development proposed in the SDG will likely generate a positive feedback cycle as more and more citizens of the world are released from inequity’s shackles and empowered to contribute to the building of a cooperative, safe, and more resilient tomorrow [1, 3, 9, 29, 30].
3. Climate change: the crisis to define an era
October 2022: Approximately one-third of Pakistan is flooded, about 1.6 million children face malnutrition, and UNICEF has received only 30% of the funds necessary to mount the required response. Amidst the stagnant waters and rubble, reports indicate that waterborne and respiratory diseases are spreading.
Climate change has become the defining issue of our time. Such was the consensus among international leaders at the 77th UNGA High-Level Meeting on Climate Change. During the meeting, LMIC leaders noted concern at the faltering pace of climate adaptation and mitigation, calling for increased investment and accountability from the wealthy nations largely responsible the climate crisis.
The Intergovernmental Panel on Climate Change (IPCC) is the UN organization charged with empirically assessing climate change on Earth. The IPCC includes experts from around the world and is recognized as the foremost international scientific authority on climate change. In 2022, the body published its sixth assessment, emphasizing the existential severity of the crisis we are facing and decrying the lack of commitment from the Global North in rectifying the present catastrophe and preventing terminal escalation of cascading climatic processes.
Thus far, the Earth has warmed approximately 1.09°C above the pre-industrial temperatures noted prior to the turn of the twentieth century. The IPCC designated a critical threshold of 1.5°C increase above pre-industrial temperatures as being associated with significant increases in multiple climactic hazards with substantial projected loss of life and infrastructure. The Paris Agreement, the global rallying point for cooperative climate action, recognizes this threshold. However, our efforts have not been sufficient to curtail our advance—this is largely due to a lack of financial commitment from wealthy nations. The IPCC predicts a 50% chance of the Earth warming to 1.5°C within the next 20 years if the current trajectory is continued. As climate change and its aftershocks wreak havoc on international trade and agriculture, erode national economies, and devastate infrastructure, people suffer.
In the Global North, rising housing prices and anger over climate inaction motivates tens of thousands to march through their streets. For their counterparts in the Global South, the impact of climate change is measured in blood [3, 8, 9, 31].
3.1 The impacts of climate change
Drought has suffocated the African Sahel and Horn leading to a vicious cycle of hunger conflict, and destabilization. Amidst the compounded suffering and concentrated misery, African leaders ask for their continent not to be forgotten.
Climate change is an active force of destabilization in our world that has wreaked havoc on the most vulnerable and its effects are accelerating. Unprecedented and devastating extremes of weather have been observed across the globe at increasing rates. Amplified monsoon seasons bring devastating flooding to Pakistan, and high-powered hurricanes batter the Caribbean and Central America. With floodwater and torrential wind come chaos, loss, trauma, destruction of livelihood, and the disruption of essential national infrastructure. In this way, climate change functions not only to injure humanity in its own right, but also functions to create conditions pathopermissive to violence and disease [3, 8, 9, 32].
3.2 Climate change risks
Climate change distinguishes itself from its Triumvirate counterparts in that it is a significant amplifier of risk. War-torn nations and refugee populations have always represented extreme vulnerability. Climate change adds to this risk in a globally pervasive and devastating manner that is without historical precedent.
Climate change’s ability to exacerbate the inequities that multiply its catastrophic impact among LMIC is why it must be designated a priority threat to global health and safety. Numerous LMIC, rendered historically vulnerable to climactic upheaval by years of inequity, lie devastated and left to recover with insufficient resources. Beneath climactic calamity and fog of war, malnourished immune-compromised refugee populations journey through stagnant, mosquito-laced waters to huddle together in unsanitary, makeshift refugee camps. The specter of disease closely accompanies them, gaining strength amidst the chaos and trauma that riddle the Global South.
To allow historically maimed LMIC nations to struggle for survival in the midst of devastating cataclysm and conflict is to permit the compounding, superaddition of risk factors that will existentially threaten the health of our international community.
Climate change has tilled through the Global South uprooting populations and fracturing infrastructure—all the while providing increasingly fertile ground for conflict and deadly disease [3, 8, 9, 33].
3.3 Climate resilient development
December 12, 2015: The Paris Climate Agreement was signed into inception and adopted by 196 nations. The agreement provided succession to the Kyoto Climate Protocol signed in 1997 and officially entering into force on November 4, 2016. The Paris Agreement is legally binding and represents the current international effort to address climate change. The two main pillars of its response are adaptation and mitigation.
Adaptation involves the active protection of vulnerable communities now—increasing current resilience against catastrophe. Mitigation works to provide sustained protection in the future
While the Paris Treaty provided a rejuvenating burst to climate change response, the battle against climate change has since stalled amidst a trend of waning investment from wealthy nations. While significant contributions have occurred, most funds have been dedicated to mitigation with little investment directed toward providing immediate, adaptive support for the LMIC nations who are being deluged and drowned beneath reiterant climatic catastrophes. Nations of the Global South must be expediently released from the shackles of poverty and hunger that constrain their national growth and must be assisted in the construction of resilient, essential infrastructure that will be fundamental to the empowered and sustained development of LMIC nations. With the five inequities reviewed addressed at minimum, adaptive measures can be more effectively and sustainably implemented, and nations of the Global South can be given freedom to undertake necessary, self-guided development [3, 8, 9, 34].
4. Geopolitical tension and state conflict
October 27, 1962: Cuban Missile Crisis. A Soviet Foxtrot Class B59 submarine carrying a nuclear payload slipped through the Caribbean off the coast of Cuba. Onboard was one Vasily Arkhipov (1926–1998), a then officer in the Soviet navy hailing from a humble background. An American destroyer had identified the vessel on sonar and began dropping depth charges. In response, the submarine was forced to dive to a depth from which Soviet radio communication could not be received. Amidst the subaquatic explosions, leaking water, and rising carbon dioxide levels, the ship’s captain and political officers noted that a war had likely started, and the submarine should fire its nuclear payload. Vasily Arkhipov, then known and admired for prior demonstrations of courage, denied the order. He is widely recognized for his decisive, maverick action that saved the world from thermonuclear war. Until now, this has been regarded as the closest humanity has been to annihilation.
Six decades have passed and we continue to live beneath an ever-growing shadow of nuclear war. Thermonuclear Armageddon has been averted by the chance, heroic action of a single individual. This is no model for sustainability and the odds say that if we continue to roll the dice as we have, we will run up against our number. For all intents and purposes, in 1962, we already had [35, 36, 37].
4.1 100 seconds to midnight
We live in an unstable world precariously balanced on a razor’s edge between peace and catastrophic war. The introduction of weapons of mass destruction (WMD) with the nuclear bomb in 1945 marked a pivotal turning point in human history. We had advanced technologically to a degree where we now held keys to our own destruction. The Bulletin of Atomic Scientists was established by Albert Einstein in solemn recognition of this. The risk and reach of conflict had critically extended from regionally limited devastation to now represent an existential, global threat. There are no winners in a nuclear conflict, it will be universally catastrophic.
From 1945 onward, the world has lived in the shadow of nuclear annihilation, and the Bulletin has closely watched. The Doomsday Clock was wound into motion in 1947 with the newly nuclear armed world set at 7 minutes to apocalyptic midnight. The Cold War Period brought the world to the brink of nuclear annihilation multiple times and advanced the clock to 2 minutes to midnight. This would be the closest humanity would dance with annihilation until 2018 when the mounting hazards of climate change and conflict returned the world to a Cold War level of risk. The progression of these crises and the introduction of a devastating, global pandemic prompted the Bulletin to advance the Clock to 100 seconds to midnight in 2020. This is closest humanity has come to existential catastrophe and the clock has remained fixed “on doom’s doorstep” ever since [4, 38].
4.2 Global arms control
June 2001: A working group with the John’s Hopkins Center for Health Security convene in Washington, D.C. for an exercise amidst growing concerns of WMD mass casualty events. The operation was called
Four of the fundamental global arms treaties are the: Non-Proliferation Treaty (NPT), the New START treaty, The Chemical Weapons Convention (CWC), and The Biological Weapons Convention (BWC). Each of these international agreements found their inception in the latter half of the twentieth century when concern for terminal catastrophe from WMD had reached a crescendo. However, despite these efforts, nuclear arsenal stockpiles remain high, and a number of nations have raised concerns regarding active engagement in biologic and chemical warfare research. The frustrated progress of global arms control has been grossly contributed to by a lack of: funding, member state cooperation, and verification/enforcement capacity.
In response to the persistent and extreme hazard from WMD, the United Nations adopted and ratified the Treaty on the Prohibition of Nuclear Weapons (TPNW) in 2020. The treaty became active January of 2021. However, reminiscent of past stumbling blocks, 69 nations abstained from becoming party; pertinently: all nuclear-armed world powers and nearly all NATO member states. The new arms control treaty provides comprehensive restrictions to nuclear weapon: development, testing, stockpile, transfer, stationing, and use. The ultimate goal of the TPNW is to achieve total nuclear arms elimination.
Superpower reluctance to ratify and commit to the TPNW renders the NPT the only binding treaty signed by the world’s nuclear armed states. In the fall of 2022, UNSG Antonio Guterres convened a meeting of United Nations member states to review and re-commit to the NPT. However, after 4 weeks of intense negotiation, a consensus was unable to be reached—chiefly because of unilateral and discordant action taken by nuclear powers.
A review of major arms treaties demonstrates a concerning trend of waning international commitment to a sustainable and peaceful future. The United States, China, and Russia have been undertaking nuclear modernization and expansion efforts, while new arms races have started regarding emerging hypersonic and anti-satellite missile technology. However, some positive progress has been made and can be celebrated.
The American and Russian Federation New START arms reduction treaty’s extension in 2021 marked a small but important step in movement toward a goal of disarmament. Since their inception, nuclear weapons have represented a ticking time bomb that have pushed humanity to the brink of annihilation on more than one occasion. We may not get another chance [4, 39, 40, 41, 42, 43, 44].
4.3 The War in Ukraine
As of the final drafting of this chapter, 40% of Ukrainian energy infrastructure has been damaged by targeted Russian missile strikes and the entire country is being affected by rolling blackouts. Amidst a coming winter, Ukrainians are being directed to stockpile clean water and warm clothes.
The War in Ukraine is testament to how intimately interconnected our world is. Russia’s invasion of Ukraine has reaped devastating tolls on Ukraine’s population and infrastructure. Europe and the world continue to live beneath the shadow of nuclear catastrophe as tensions mount between world powers and Ukraine’s Zaporizhzhia Nuclear Power Plant sustains collateral damage from the conflict.
However, thus far, some of the most devastating global effects from the conflict in Ukraine originated not from bullets or bombs, but from a critical snare of the global supply chain. The conflict has thus far pushed millions into extremes of poverty, significantly exacerbated the risk of famine, and reversed years of developmental progress.
SG Guterres and the UN quickly noted an emergency as Ukraine’s grain exports plummeted following Russia’s invasion. The War in Ukraine resulted in a critical disruption of global food supply that casts many impoverished regions into deeper risk of famine. The Black Sea Grain Initiative, brokered by Turkiye and the United Nations, provides an example of a successful, expeditious, and relatively equitable international response to emergency.
The disruption of the international energy supply chain prompted a global energy crisis. Nations in the Global North and South have endured significant collateral damage including: economic downturn, escalating inflation, rising costs of energy and food, internal destabilization, and escalating geopolitical tension. The impacts of war are unevenly distributed with impoverished nations rendered super-vulnerable to destabilizing collateral forces spinning off from regional and international conflicts [45, 46].
4.4 Global trends in conflict
October 2022: An attach on a Somali hotel by Al Shebab kills nine innocents and wounts more while interstate violence in Sudan’s Blue Nile State has filled hospitals past capacity with wounded. The fighting has resulted in significant displacement that has forced fleeing refugees into crowded, unsanitary conditions. This represents a trend of irregular/asymmetric violence that has torn apart nations of the Global South for decades.
Conflict is grossly divided into two major types: interstate conflict and intrastate conflict. Wars between nations have decreased in frequency since the end of World War II. However, intrastate conflicts have increased in frequency at an accelerating rate, particularly with the Global South. Since 2010, there has been a noted threefold increase in major civil war frequency, a sixfold increase in conflict mortality, and an approximately 60% rate of conflict recurrence.
This internal, irregular violence has been tearing nations of the Global South apart taking an especially heavy toll on the African continent. At the 2022 General Assembly, SG Guterres held a High-Level Meeting on the Sahel. During the meeting, SG Guterres expressed significant concern over the progressing risk and complexity of the Sahel’s geopolitical situation as climate disruption, energy crisis, famine, and crippling impoverishment destabilize nations and spark intrastate violence. The increasingly recalcitrant and intractable nature of conflict is amplified by this noted uptick in complexity with many intrastate conflicts now proving less responsive to traditional political and diplomatic measures of resolution [33, 47, 48].
4.5 The impacts of conflict
Conflict takes a heavy toll. The acute human morbidity and mortality are the most immediate and readily seen impacts of conflict. However, the aftershocks of suffering that ripple through shattered national infrastructure prove equally devastating.
The ongoing Yemeni Civil War can prove instructive regarding the compounded risk levied on populations of the Global South. The devastation of Yemen’s water and sanitation infrastructure by conflict produced widespread, unsanitary, and biologically hazardous conditions. The addition of unseasonal and significant rainfall and flooding to this caustic mixture resulted in the exposure of a chronically malnournished war-torn population to a compounded infectious disease risk. This interaction of complex biologic risk with extremes of vulnerability facilitated what would become the worst cholera epidemic in modern history.
In the case of the ongoing Civil War in Syria, more than half of the nation’s population has been displaced and catastrophic damage has been done to over half of essential Syrian medical, educational, and energy infrastructure. This disruption in essential infrastructure has rendered the nation’s chronically war-torn resident population especially vulnerable to climatic and contagious risk resulting in excess morbidity and mortality and a decline in Syrian life expectancy by 5 years. Population displacement from concurrent crises has caused significant increased in migrant populations resulting in a strain and fracture of critically underpowered international and national refugee support networks. This ultimately exposes exceptionally vulnerable, migrant populations to extremes of risk resulting in tragic loss of life. Standing as grim testament to this, the Mediterranean Sea has slowly become a graveyard to many migrants fleeing conflict and catastrophe.
In 2022, global inflation rose to 8.8%. The IMF cites the War in Ukraine and the COVID-19 pandemic as key contributors to the global financial crisis. While both Global North and South have experienced economic impact, LMIC have borne the brunt of the injury. In their annual meeting last year, the IMF and World Bank Group expressed concern double-digit rates of inflation which have impacted 40% of countries in sub-Saharan Africa—critically impairing essential national development and providing fertile soil for seeds of conflict and disease to take root [1, 15, 33, 49].
4.6 A road to peace
An overabundance of military spending and a lack of investment in sustainable, global development are actively contributing to global risk. Sustainable, global peace will require a significant shift in national priority and finance away from defense spending. Weapons must be exchanged for plowshares and soldiering must bow to solidarity. The volatile, root causes of conflict will need to be tilled up from the soil of LMIC in the Global South to make way for the sustainable development that will need to occur if we are to effectively safeguard our collective, global health security. The mechanisms to affect this development have been defined and set into motion, the lacking component has been fuel and international investment. In this dilemma, military budget reduction may provide a parsimonious and elegant way to power peace through disarmament. In addition to a treaty representing a new global commitment to disarmament, the United Nations brought
5. Contagion: the curse of inequality
Infectious disease has long been an intimate enemy of humanity. The flea vector-borne Bubonic Plague, H1N1 Influenza pandemic of 1918, and ongoing AIDS and COVID-19 pandemics offer humbling testament to human society’s unique vulnerability to this curse. Contagion distinguishes itself among the Toxic Triumvirate in its long understood and inextricable relationship with conditions of poverty and inequity.
In the mid-nineteenth century, a young Dr. Rudolf Virchow was dispatched from the Prussian Ministry of Health to investigate a typhus epidemic that had been reported in the city of Upper Silesia. The dawn of the Industrial Revolution in the Global North resulted in a trend of urbanization that quickly exceeded the infrastructural carrying capacity of early cities. Crowded living conditions, poor air quality, and lack of sanitation provided conditions ideal for the spread of early urban diseases such as cholera and epidemic typhus.
Dr. Virchow was struck by the abysmal conditions of impoverishment and misery he observed among the urban poor of Upper Silesia. In his
In nineteenth century Prussia and throughout human history, contagious outbreaks have demonstrated themselves to be exquisitely socially and environmentally. The impoverished, unsanitary, and environmentally unstable conditions that plague the LMIC represent a dangerous compounding of biologic hazard. Within the growing urban-slums of the Global South, vulnerable populations are exposed to extremes of infectious disease risk that are transmitted and shared across our international community through international trade and travel. In our increasingly interconnected world, the risk endured by one population is shared by all [51, 52, 53, 54].
5.1 Diseases of poverty: the poor man’s burden
Every 2 minutes a child dies of malaria. Infectious Diseases of Poverty (IDoP) are estimated to take 14 million lives annually with children disproportionately impacted. In this way, the young generations of the Global South who will be faced with unprecedented challenge are crippled at the outstart by preventable/treatable IDoP. The infections that unnecessarily curse the world’s most vulnerable are myriad, but malaria, tuberculosis (TB), and HIV have proven exceptionally devastating. This apty named, “Unholy Trinity,” acting in concert with diarrheal illness and Neglected Tropical Disease (NTD), have plagued Global South for decades—devastating populations, crippling economies, and paralyzing critical development.
Malaria is a preventable illness that has been successfully eradicated from many regions of the globe. In 2020, the WHO estimated there to be 241 million cases of malaria worldwide with 627,000 total deaths. The African continent is home to 95% of malaria cases and 96% of malaria deaths—80% of which are children under 5 years old. The WHO global malaria strategy is designed to achieve 90% reduction in cases and deaths by 2030, but progress has slowed. While COVID-19 caused significant disruption to health systems and medical care across the world, some significant advances in malaria control have been achieved and retained. These include the recent introduction of a vaccine for malaria and the historic reduction in annual childhood malaria mortality from 900,000 deaths in 2000, to approximately 650,000 in 2019. Insecticide-treated bed nets were credited with being responsible for approximately 68% of the cases averted. Malaria is a treatable and eradicable disease that has been successfully banished from many nations of the Global North. It is time the Global South is released from this burden as well.
In 2021, one child died of AIDS-related causes every minute. The Joint United Nations Programme on HIV/AIDS (UNAIDS) reported 38 million people living with HIV and 650,000 AIDS-related deaths in 2021. The majority of deaths occur in children who comprise 4% of people living with HIV but 15% of age-related deaths. In 2021, an estimated 53% children living with HIV lacked access to HIV treatment. UNAIDS reports that the lion’s share of HIV incidence, morbidity, mortality, and lack of treatment access is concentrated among key vulnerable global populations. Disruptions in health infrastructure by COVID-19 caused a significant loss of global progress in the battle to control AIDS with many countries experiencing increasing incidence rates. Inequity in treatment has grown as international AIDS support has fallen by 57% over the past decade with UNAIDS calling for renewed vigor and attention to be given to reducing disparities in global HIV/AIDS treatment and outcome.
Tuberculosis (TB) is a curable and preventable disease, and the second leading infectious cause of death worldwide. It exists in a viciously synergistic relationship with HIV’s immunosuppression and is led only by COVID-19 in global infectious disease (ID) mortality. LMIC account for 98% of reported TB cases with countries such as India, Indonesia, Pakistan, Nigeria, and Bangladesh claiming some of the highest TB prevalence worldwide. As with the global AIDS response, international funding has been declining over time, falling 8.7% between 2019 and 2020. The UN has committed to ending the TB epidemic by 2030; however, if we are to reach this goal, channels of support must be bolstered significantly [55, 56, 57, 58, 59].
5.2 COVID-19: a grim teacher
Even a perfect medicine will be rendered inert when given in solution with inequity. This has been a public health lesson expressed ad nauseam by the cyclic, zoonotic pandemics that have become an unnecessary part of our reality. AIDS, MERS, SARS, Ebola, and now COVID-19 outbreaks/pandemics reiterantly wreaked havoc across the globe, becoming increasingly economically and sociopolitically devastating over time.
Over the past 2 years, COVID-19 has infected 767 million and killed 6.9 million, with the highest rates of excess death observed in LMIC [60]. COVID-19 crippled the global economy acting in tandem with the War in Ukraine to cause skyrocketing inflation and declining rates of national economic growth that have paralyzed or reversed developmental progress.
Both COVID-19 and non-COVID-19 zoonotic pandemics continue to represent an extreme global risk. Currently, the UN and WHO estimate that only 34% of low-income country populations have been vaccinated against COVID-19. The pandemic’s persistence is owed in part to COVID-19’s consistent exploitation of the vulnerabilities inherent to undervaccinated populations. One manifestation of this can be found in the mutated viral variants that develop in the shadows of vaccination. These mutant strains have continued to fuel the pandemic’s slow-burn course toward global and regional endemicity [4, 53, 54, 61, 62, 63].
5.3 Emerging diseases and pandemic risk
October 2022: Pakistan remains devastated from atypical monsoon flooding, which inundated one-third of the country. Reports from the ground describe increasing rates of waterborne illness and respiratory infection with maternal and fetal mortality rising significantly.
Emerging infectious diseases (EID) are infectious diseases to which we are naïve either because we have not met them, or because the disease we used to know has changed character physically, spatially, or biologically.
EID are comprised mostly of zoonotic pathogen such as coronaviruses, hemorrhagic fever viruses, and avian/porcine-derived influenza viruses, and represent an ever-growing threat to global public health. Over the past three decades, outbreaks of EID have been noted to increase in frequency—this disproportionately occurring within impoverished nations of the Global South. The increasing rate of emergence has been contributed to by a myriad of factors including: global warming, environmental change, dangerous animal husbandry practices and growing antimicrobial resistance. Underregulated microbiologic gain-of-function research represents a significant and growing hazard overall contributing to a historically unprecedented level of pandemic risk.
Avian influenza viruses, such as H5N1, naturally circulate among waterfowl in which they evoke a limited, mild upper respiratory inflammatory response upon initial infection. These viruses have the potential to be transmitted to chickens, pigs, and humans in whom they can elicit a much more severe and lethal inflammatory response. Of particular concern are recently detected, highly virulent avian viruses such as H5N9, which have caused numerous, limited outbreaks since identification in 2003 associated with a case-fatality rate of 50%. These viruses pose an ever-present risk as they may be only a mutation away from acquiring the enhanced human-human transmission needed to be pandemic-eligible, hereby very grossly defined as pathogen with Basic Reproductive Number (R0) > 1.
Porcine (swine) influenza viruses, such as H1N1, regularly circulate among pigs, resulting in ongoing outbreaks. Pigs may develop a mild respiratory disease upon infection, but the inflammatory response is usually limited and not associated with high mortality. Concerningly, pigs are also susceptible to infection from avian and human-borne influenza viruses. This leads to one of the greatest risks of influenza: mutation. Viruses mutate and produce variants—this has been clearly demonstrated by COVID-19. Influenza viruses are particularly prone to significant genetic mutation and alteration with risk rising substantially when animals are co-infected with several different strains. For this reason, mass animal husbandry practices such as Concentrated Animal Feeding Operations (CAFO) present a high outbreak risk by providing an ideal environment for the mixture and mutation of porcine and avian influenza viruses as well as an immediate interface for human acquisition.
Earth currently has about 8 billion inhabitants with projections estimating population growth to 9 billion by 2045. The majority of this population increase is projected occur within urban centers and has already resulted in the development of “megacities” across the globe. The United Nations defines a “megacity” as an urban center having a population in excess of 10 million. There are approximately 30–40 megacities worldwide and this number is expected to rapidly increase with most development occurring in LMIC. The inherent risk to current trends in urbanization presents an enormous public health hazard when superadded to the volatile mixture of malnutrition, fractured infrastructure, and conflict that inundate nations of the Global South. UN-Habitat estimates that approximately one-third of LMIC populations live in urban “slum” settings characterized by pathopermissive conditions of poverty, lack of sanitation, and population growth in excess of infrastructural carrying capacity. It is theorized that the Ebola virus outbreak sparked in West Africa was fanned into flame by a combination of deforestation and pathopermissive urban conditions of impoverishment. In modern day LMIC nations, as in 1848 Upper Silesia, pathopermissive urban-slum conditions introduce significant levels of biologic risk and provide fertile ground for the introduction and dissemination of contagious pathogen [53, 54, 64, 65, 66, 67, 68].
5.4 Outbreak’s golden hour: insight from sepsis care
Sepsis is a dangerous physiologic phenomenon and one of clinical medicine’s oldest and most lethal enemies. It can occur when an infection or toxin has spread from its source point into the bloodstream. The pathogen’s systemic dissemination sets off a lethal cascade of events that drop blood pressure, starving the organs of oxygen. In its advanced state, sepsis leads to multisystem organ failure and death.
The importance of early action in the treatment of sepsis is paramount. Ideally, an infection is immediately treated at its point source before dissemination occurs. Once a pathogen has entered the bloodstream and initiated a septic cascade, antibiotics must be administered within 1 hour. A moribund history has taught us that after this point mortality increases significantly. These principles of medicine can theoretically be extrapolated and applied to the management of infections within our international body. As in clinical medicine, prevention of infection is the first priority. When this fails, and an infection develops, it is critical to contain the outbreak at its source before it can disseminate through our shared arteries of trade and travel. Just as in septic care, rapid, decisive, and effective action must be taken within a critical window of time to avoid bad outcomes. The “Golden Hour” of sepsis provides an example of a systems approach to ensuring critical action be taken in appropriate time. There has not been a directly analogous golden window of action that has been defined for source containment of outbreaks. The variation in pathogenicity characteristics between pathogen naturally confounds the ability to establish broad, universally applicable protocols. However, in the sections that follow, I will attempt to utilize recent modeling studies and prior zoonotic pandemic patterns to clarify a possible action window for source containment of pandemic-eligible pathogen that could be used as a starting point to help inform a standardized, systematic approach to international outbreak response [69, 70].
5.5 Insight from exercise and disease modeling
Beginning with the American
In March 2021, the Nuclear Threat Initiative and the Munich Security Conference collaborated to stage a high-level, tabletop-modeled pandemic scenario using current global infrastructure and response protocol. The scenario chosen was conservative, pre-supposing international cooperation and functional national health infrastructure. The exercise involved an unusual outbreak of monkeypox in a fictional nation with intact infrastructure. The fictional inoculation and introduction occurred during a national holiday on May 15, 2022. In June, the nation’s national health department identifies and reports a novel, mutated strain of monkeypox virus to have infected 1400 citizens with four deaths reported to that date. There is no immediate evidence of international spread. An internationally supported containment response is then undertaken in an effort to establish disease source control.
The next scenario timepoint occurs 6 months later. In the interim, the international public health response had been unable to establish source control fast enough and the virus had internationally disseminated. As of January 10, 2023, the virus had spread to 83 countries with 70 million reported cases and 1.3 million fatalities. Critical trade and supply lines lay disrupted, and the global economy had come to a standstill [53, 54, 64, 71, 72, 73, 74, 75].
5.6 Lessons from history
SARS, Ebola, and COVID-19 all-share devastating similarities and can prove historically instructive. SARS was first detected by Chinese health authorities in Guandong province on November 18, 2002. In February 2003, SARS had broken from its point of origin and was detected in Vietnam, Canada, and Hong Kong. The WHO was only officially notified of the outbreak in February with a global alert issued in March, by which time the virus had spread further to Singapore and Taiwan. In this instance, the lack of Chinese international cooperation precluded any ability to control international dissemination. The SARS coronavirus was confirmed present in more than three additional countries 4 months following initial detection.
In the case of Ebola in 2014, West African nations proved internationally cooperative but lacked the essential infrastructure necessary to achieve source control. Researchers believe that the index outbreak inoculation occurred in December 2013 in Guinea. The infection spread undetected for months until March 2014 when health officials announced an outbreak of a mysterious hemorrhagic fever virus that “strikes like lightning.” That same month, Liberia reported similar cases. Medicines Sans Frontières (MSF) immediately responded but international aid was otherwise slow to follow. By April, the virus had spread to Mali followed by Sierra Leone in May. In August 2014, the disease reached the doorstep of the Global North. The United States, Spain, and the United Kingdom had active Ebolavirus cases in hospital. In the 2014 Ebola outbreak, the virus was provided an opportunity to emerge, propagate, and disseminate within a period of 4 months, largely due to pathopermissive conditions created by a resource-strapped public health system and confluent environmental risk factors. In the absence of effective national health infrastructure, source control was critically stymied, and the golden window for containment passed quickly.
COVID-19 represents the latest zoonotic pandemic. Its timeline is strikingly similar to that of SARS, but its impact has been orders of magnitude worse. COVID-19 was likely circulating in Wuhan in November of 2019. Its source of introduction remains unknown though the animal-to-human interface at wet markets and the resident institute of virology each pose known and significant infectious disease risk.
Two possible COVID-19 index cases had been identified on Nov 17 and Dec 1. The outbreak became noted by Chinese health authorities in December, but an international warning was not given. In January, China acknowledged an outbreak of acute pneumonia associated with a respiratory virus. However, conflicting reports were provided about transmissibility which proved critically misleading. By mid-January, COVID-19 had been reported in Chinese major urban centers, Thailand, Singapore, Hong Kong, Japan, France, and the United States. The WHO declared an international emergency on January 30, 2020, with the declaration of an international pandemic delayed into March. With international hands tied by disinformation and lack of cooperation, COVID-19 was able to rapidly disseminate from its point of origin and become internationally systemic within a period of 3 months.
An examination of modeling scenarios and pandemic trends in aggregate reveal a disturbingly common theme: We are consistently too late. By the time international support has been mustered and action has been taken, the horses are well out of the barn. SARS, Ebola, COVID-19, and pathogen modeling studies demonstrate a consistent ability for pandemic-eligible pathogen to internationally disseminate within approximately 3 months if source control is not achieved. This gross, roughly estimated 2–3 month “Golden Window” of outbreak response may be decisive in determining whether or not a pandemic-eligible pathogen will be able to be contained within its region of introduction. The above-proposed window is only a rough sketch generated from relatively scant data. Further, rigorous clarification of a pandemic response timeline may prove very beneficial in systematically orienting and organizing decisive and timely international response to outbreak containment [53, 54, 76, 77, 78].
5.7 One health, one risk, one future
Humanity stands at an ethical and existential crossroads and time is of the essence. Every minute a Somali child is admitted for severe malnutrition. The next, another has perished from malaria. At the end of the day, at least 800 more have been lost to preventable, diarrheal illness.
The development and integrity of LMIC nations of the Global South are actively being undermined by preventable disease, intrastate conflict, and climatic catastrophe. Our shared world continues to be repeatedly challenged by preventable pandemics that are proving increasingly devastating over time. COVID-19, the latest pandemic iteration, has not been controlled and is now moving toward global endemicity. All the while, the risk of another internationally paralytic pandemic from EID remains at a historic high and the stumbling blocks that stymied our prior containment responses to SARS, Ebola, and COVID remain present.
We live in an era of unprecedented risk that is shared by all members of our international body. The crises jeopardizing our global health security are interrelated and complex, but the solutions that have been defined are relatively elegant in principle: We must expediently invest in the empowering, sustainable development of our neighbors in the Global South. The health security of our international body will require all member nations to be developmentally healed and infrastructurally functional. Central organ systems critical to global homeostasis must also be operational and properly funded. It will be only through solidarity that we can hope to effectively and sustainably safeguard the health of our international community [9, 53, 54, 79].
Acknowledgments
I am a new author and a trainee in the field of preventive medicine and public health. In helping to usher this call to action, I stand on the shoulders of giants in the field who have clarified the present threats and defined potential solutions. This chapter was able to be completed only with the support of a village of mentors and colleagues. I would first like to sincerely thank IntechOpen for their dedication to Open Access publishing and information equity; and for the privilege and opportunity to contribute to a discussion and topic that is my passion. I would also like to thank the faculty of the University of California San Diego (UCSD) Preventive Medicine Residency Program and San Diego State University (SDSU) School of Public Health (SPH) for the phenomenal education I have been provided and for the faculty support I’ve received throughout this process. I’d like especially to thank SDSU SPH Divisions of Epidemiology & Biostatistics and Environmental Health for providing me invaluable preparation for the writing of this chapter.
I deeply thank my colleagues who have critically aided me in writing, including but certainly not limited to: Chief Editor Mr. Isaiah Briggs of Harvard Divinity School, Lead Editors: Mr. Joshua Kapusinski author of The Awakening (2022), and Ms. Maria Alexandra Hernandez and Mr. Haider Ghiasuddin of Geisel School of Medicine at Dartmouth for their invaluable assistance.
I would like to thank Mr. Antonio Guterres and Mr. Volodymyr Zelenskyy for their outstanding and truly inspirational international and national leadership during this time of extraordinary crisis. I would also like to thank MIT Emeritus Professor of Linguistics Noam Chomsky, as well as the late Yale Professor of Law, Arthur Allen Leff (1935–1981), for the pivotal role they have played in my (and many others) intellectual and academic development. I thank Al Jazeera for their excellent and equitable coverage of global news, and for making a point to uplift the voices of those seldom heard. I deeply admire and thank Medicines Sans Frontiers (MSF) for their critical and relentless work aiding migrants and refugees, and for MSF’s consistent, strong advocacy for the world’s underserved. Finally, I would like to thank and acknowledge Mr. Nikola Tesla (1856–1943) for his inspiringly genuine and wonderful approach to nature and science, and most importantly, for his revolutionary development of the Alternating Current that powers our world and for which he is seldom recognized.
This chapter is written for, and dedicated to, my brothers and sisters in the Global South, who have endured unfathomable, preventable suffering for centuries without reason. I am an incredibly insufficient author in advocating for the prompt and sustainable development of LMIC; however, I do hope that this chapter can direct attention and action toward this goal as it is critical to the preservation of global health security. I pray the human species will find the moral courage required to heal our neighbors and ensure a safe tomorrow for our children. This chapter represents an independent work generously supported through the IntechOpen expanded sponsorship opportunity program.
Notes/thanks/other declarations
In closing, I would like to thank my Mom and Dad, who have worked hard to provide my little brother and I with opportunities that were not available for them.
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