"Protecting Health Security in a Disordered World." CSIS Commission on Strengthening America's Health Security, Center for Strategic and International Studies, September 13, 2018. Accessed October 01, 2020.

The reality of the disordered world demands U.S. leadership and action to ensure health security.

Photo Credit: Spencer Platt/Getty Images

A Iraqi family who fled recent fighting near the city of Mosul prepares to sleep on the ground as they try to enter a temporary displacement camp but are blocked by Kurdish soldiers on July 3, 2014 in Khazair, Iraq.
A Iraqi family who fled recent fighting near the city of Mosul prepares to sleep on the ground as they try to enter a temporary displacement camp but are blocked by Kurdish soldiers on July 3, 2014 in Khazair, Iraq. Spencer Platt/Getty Images

Key Challenges

Increasing Conflict and Displacement

Violent conflict is on the rise after decades of decline. Since 2010, the number of major violent conflicts has tripled,1 and the average duration of civil wars in progress has increased to more than 20 years.2 Record numbers of unresolved wars, concentrated in the Middle East and Africa, show no signs of abating. As a result, we are witnessing the highest levels of displacement on record, with 68.5 million people forcibly displaced worldwide as of June 2018, compared to 33.9 million in 1997.3 Over 84 percent of refugees are hosted by developing countries, and the top six-refugee receiving countries—Turkey, Pakistan, Lebanon, Iran, Uganda and Ethiopia—increasingly struggle to maintain their own political stability.4 Much of the exploding displaced population lacks regular access to basic health services.

Demographic Shifts

Populations of adolescents and young people in many places have reached historic levels, with some crisis-affected countries expected to double their populations in the next 20 years, further challenging health and stability in fragile settings. This “youth bulge” is associated with higher risks of instability and conflict and undermines these countries’ ability to meet population needs for health, education, and employment. Addressing these demographic issues requires expanded access to voluntary family planning and education, while harnessing the dynamism of these young populations.

Vulnerable Populations – Women and Girls

Populations that were already vulnerable are particularly affected in the disordered world context: women and girls comprise over 50 percent of refugees, internally displaced, and stateless populations, with little access to family planning or maternal health services and at high risk of sexual violence and exploitation.5 Over 32 million women and girls of childbearing age are in emergency situations.6 Maternal mortality is on average 2.5 times higher in conflict and post-conflict countries, and over half of all maternal, newborn, and child deaths occur in about 50 countries categorized as fragile states.7

Addressing the glaring gap in access to services for women and girls in crisis situations – including family planning, education, and gender-based violence protection – is a critical component of crisis response. When women and girls in fragile and crisis settings are healthy and empowered, they play a critical part in building resilience, mitigating conflict and promoting recovery. Significant reductions in child and maternal mortality have been achieved through immunizations, improved sanitation, and expanded access to voluntary family planning. In recent years, high-level attention has turned to the acute needs of women and girls and their role as agents of change, including in conflict and fragile settings. The stage is now set to do far more in this area.

Geopolitical Sensitivities

Looking forward to where future conflicts and instability could occur, far greater attention must be paid to those crisis-prone, geopolitically sensitive countries which, due to their specific forms of malgovernance, now threaten to ignite destabilizing, public health-driven crises. These countries include North Korea, Venezuela, and Ukraine. Health security should be better incorporated into geopolitical considerations around these places.

Global Developments

Innovation and intellectual heft are already being applied to the unique problems posed by the disordered world. The European Union is leading on access to education, while UN agencies including WHO, UNICEF, UNFPA, and UNDP are devoting considerable energy to innovating in response to complex new demands. Many institutions, such as Gavi, the Global Fund, MSF, and ICRC, have begun to pivot to operating by new rules and practices in these realities.

In May 2016, the United Nations Security Council adopted Resolution 2286, condemning attacks against health facilities and personnel in conflict situations and urging action to prevent and respond to such attacks.8 Later that month, then-United Nations Secretary-General Ban Ki-moon convened the first ever World Humanitarian Summit in Istanbul, held in recognition that rising global humanitarian demands greatly exceed capacities and resources, pose complex new operational and security challenges, and demand new, improved approaches that transcend siloes and strengthen accountability, data, coordination, management, and financing.9

U.S. Leadership and Action

U.S. leadership and commitment are essential. The United States accounts for roughly half of the resources dedicated globally to address humanitarian crises, through direct bilateral programs, non-governmental organizations including faith groups, and UN agencies and other international organizations. Humanitarian emergencies align or overlap with geopolitical zones of high importance to the United States on security and counterterror grounds, including the Middle East, South Asia, and Africa’s Horn and Sahel regions. Americans lead UNICEF and the World Food Program and occupy critical positions in the UN High Commission for Refugees, UNDP, and other agencies. Within the U.S. government, PEPFAR and PMI are adjusting to meet the challenges of the disordered world, and the congressionally-mandated, bipartisan Task Force on Extremism in Fragile States launched in April 2018 to develop recommendations to more effectively prevent the underlying causes of extremism in fragile states, including burden-sharing approaches with international partners.10 The U.S. voice remains vitally important in shaping the response to the health security threats present in the disordered world.

Maintaining the centrality of U.S. leadership on health security requires the prioritization of the disordered world in stated U.S. policy goals and strategy. Congress will play a critical role in shaping the concrete agenda for innovation and higher levels of U.S. engagement. Winning health battles in the disordered world will also require a high degree of diplomacy and sustained commitment to an alliance-based model to reinforce and sustain international norms as laid out in international humanitarian law. The United States must engage partners not only bilaterally but multilaterally to support and strengthen international capacity to track, grasp, and anticipate health security crises, shape outcomes early and preempt worst outcomes, and better manage these burgeoning challenges.

  1. Uppsala Conflict Data Program, 2017, 

  2. James D. Fearon, “Civil War & the Current International System,” Daedalus 146, no. 4 (2017): 18-32, 

  3. UNHCR, “Figures at a Glance,” updated June 19, 2018, 

  4. Ibid. 

  5. UNHCR, “Women,” accessed August 2018, 

  6. UN OCHA, “Global Humanitarian Overview 2017,” 2016, 

  7. UN Women, “Facts and figures: Peace and security,” accessed August 2018, 

  8. United Nations Security Council, “Security Council Adopts Resolution 2286 (2016), Strongly Condemning Attacks against Medical Facilities, Personnel in Conflict Situations,” May 3, 2016, 

  9. Agenda for Humanity, “World Humanitarian Summit 2016,” 2016, 

  10. USIP, “Task Force on Extremism in Fragile States,” 2018, 

Next Article