Failing States as Epidemiologic Risk Zones: Implications for Global Health Security

What Is a (Failing) State?

Since the 1990s, researchers in the social sciences have compiled additional case studies of state failure and collapse from places like Zaire, Sudan, Haiti, Colombia, Somalia, Sierra Leone, Sudan, Afghanistan, and others.^15-22 This work has made important contributions to the study of instability and conflict in the contemporary era, but it remains limited by the one-way directionality of language. Fituni's term “thirdworldization,” for instance, is an elastic concept that suggests a reversible process of decline. “Failed state” on the other hand, implies a fatal descent into anarchy from which there is no return—at least not without international intervention. Case studies of failed states, however, consistently reveal that political decline and collapse are followed by regeneration of informal governance structures that can go on to form the basis of a new criminal state.^{13,17,20,22,23} But this process cannot be understood with static definitions of the state.

In one of the first studies of failed states, for instance, William Zartman defined the state as “the authoritative political institution that is sovereign over a recognized territory.” ^15(p5) Many case studies, however, describe disconnections between sovereignty and territory during times of state failure.^17-20,23 Zartman himself even defined political collapse as “marked by the loss of control over political and economic space.” ^15(p9) But there was no subsequent revision of his original definition of states. These unresolved contradictions have hindered empirical research, and the study of failing states has been somewhat marginalized in the social sciences.^18,19,22

This article proposes that state failure can be understood only if the state itself is first redefined as territorially dynamic with natural cycles of expansion, contraction, collapse, and regeneration. As Martin Doornbos has stated, “… it is indeed conceivable to regard collapse as part of processes of state reconfiguration and formation.” ^22(p46) This revised definition of the state makes it easier to understand how disconnections between sovereignty and territory create the conditions Fituni described as “thirdworldization.” These include violent conflict, environmental destruction, strongman rule, increased political corruption, reduced life expectancy, and outbreaks of infectious disease.^{13,15,18,20,21,23} The reasons for this can be found in the “ungoverned spaces” created by territorial instability.

Territorial Instability and Violent Non-State Actors

When a failing state contracts politically, it leaves behind a stateless space that some researchers have termed a “grey zone.”^24,25 Grey zones remain within the mapped cartographic boundaries of a state but are no longer under the control of any government. This is risky for human health for 2 reasons: (1) public health programs are temporally and spatially interrupted in grey zones, and (2) the lack of formal governance structures facilitates the expansion of violent non-state actors. The term “violent non-state actors” is used to describe armed groups that are not affiliated with any government, including warlords, militias, organized crime groups, and terrorist organizations.^26-28 Organized crime groups need militias to protect their cargoes of illicit contraband from theft and raiding. Militias and terrorist groups need revenue to fund their insurgencies, so there is a natural convergence of activities even between ideologically divergent violent non-state actors. Violent non-state actors expand in grey zones because there is no threat of arrest or incarceration in a stateless space. Once established, they establish a monopoly on violence and create new post-state forms of conflict and governance (sometimes termed “warlordism”) based on rent-seeking and resource extraction.^23,29-32

All of these conditions make grey zones spaces of enhanced epidemiologic risk, especially in densely populated urban areas. Public health work is interrupted or abandoned as the retreating state contracts. Basic municipal services like trash removal, water treatment, and sewage disposal lapse or become shifted to the informal economy. There are no sustained vector control programs, and critical record-keeping (such as registries of births and deaths) may be interrupted for extended periods of time. This makes it difficult to measure health declines: Grey zones create dangerous blind spots in global health surveillance systems.

In some cases, nongovernmental organizations (NGOs) have stepped in to provide critical services in stateless spaces. ³³ But without reliable electricity, infrastructure, or supply chains, the impact of NGO work is limited. There are also major security risks for NGOs operating in grey zones. These can include physical threats against health workers and raiding and theft of essential humanitarian supplies.^34,35 One New York Times article from 2011 estimated that up to half of the international food aid sent to starving Somalis was diverted by theft or raiding. ³⁶ The NGO Doctors Without Borders abandoned work in Somalia in 2013 after 16 staff members were killed following a period of “increasing threats, thefts and other intimidating incidents.” ³⁷

In addition to the interruption of public health and sanitation activities, grey zones also increase risks of disease outbreaks driven by violent conflict. ³⁸ Andrew Price-Smith has written extensively about how warfare serves as a “disease amplifier.” ³⁹ Warfare destabilizes ecologies and economies, disrupts subsistence, and aggregates large numbers of young men in military encampments, where disease is easily spread. Noncombatant populations are displaced into unfamiliar territory, where they may or may not have access to clean drinking water or basic sanitation facilities. All of these activities increase the likelihood of spillover events by forcing crowds of impoverished refugees into unfamiliar ecological zones under conditions of severe psychological and nutritional stress.

Conflicts between rival violent non-state actors may have greater potential to spark epidemics than conflicts between sovereign states. While violent non-state actor conflicts are usually smaller in scale than regular wars, they have the potential to create greater environmental disruption. Violent non-state actors do not maintain professional armies. They do not have rules of engagement or institutional constraints on the use of violence. They also intentionally target productive enterprises under the control of rivals. This can include farms, businesses, schools, irrigation systems, and hospitals.^40,41 Prolonged violent non-state actor conflict can leave large numbers of people deeply impoverished, with no housing, medical care, or public services for extended periods of time. Famine, disease, and refugee crises frequently follow.

In Somalia, for instance, years of state failure and violent non-state actor conflict in the 1990s left citizens with “no national administration … no formal legal system; no banking … no public service; no educational and reliable health system; no police and security service; no electricity or piped water.” ^17(p78) With no security services to protect property, there was massive looting of public infrastructure, including water and sewage pipes that were sold for scrap metal. In 1993, a New York Times reporter described Mogadishu as completely destroyed by “marauding gangs … organized by warlords and merchants” scavenging for unprotected property that could be sold in the informal economy. These groups “systematically … stripped … roofs, windows, wiring … cut down telephone cables and dug up electrical wires for the copper inside. They tore up the streets to steal the sewer pipes, leaving sewage to pour in the streets.” ³⁴ In rural areas, rival violent non-state actors intentionally destroyed farms and irrigation systems in enemy territory, creating severe humanitarian crises. ¹⁷

Approximately 30,000 people were killed in Somalia's armed conflicts in the early 1990s. Between 200,000 and 300,000 died in the famine and drought that followed. ⁴² Somalia's infant mortality rate is still estimated to be one of the highest in the world, and life expectancy remains low. There are also high rates of infectious and parasitic diseases like typhoid, dengue, malaria, and rabies. ⁴³ According to one group of researchers, rates of polio vaccination in Somalia declined to only 35% in the early 2000s, leading to resurgent outbreaks. Health professionals were unable to vaccinate vulnerable populations because of security risks and “long-term inadequacies in cold chain and logistics.” ^44(p)

Violent non-state actors also make grey zones uniquely risky for women and children. Insurgencies and organized crime groups are composed of male coalitions, and predation on girls and women is common. More than 15,000 women and children have been abducted from grey zones in Sudan since the 1980s. According to Human Rights Watch, the Nigerian group Boko Haram kidnapped hundreds of young girls in Nigeria and forced them into arranged marriages or desolate “rape camps” similar to those found in the Bosnian conflicts of the 1990s. ⁴⁵ A similar pattern appears to be unfolding in the cartel zones of Mexico and Central America. ⁴⁶ In addition to the trauma of kidnaping and rape, women in grey zones are also vulnerable to sexually transmitted diseases (including HIV), pregnancy complications, and increased maternal mortality. As captives, they have little or no access to medical care, even if there are clinics and hospitals located in the region.

Violent non-state actor conflicts frequently stabilize through the inscription of informal territorial boundaries between rival groups.^23,40 Inside these spaces, warlords or militias regulate commerce by establishing a monopoly on violence.^23,47 The result is a predatory post-state system of governance, sometimes described as a “warlord mini-state” or “protection racket state.”^47-49 Areas under violent non-state actor control are characterized by intensified resource extraction with no public services. This further destabilizes the natural environment in ways that increase risks of zoonotic disease crossover. For these reasons, failing states should be considered high-risk zones for the emergence and amplification of novel pathogens, as well as for the reemergence of preventable infectious disease.

Post-State Ebola in “Greater Liberia”

Events in West Africa in the 1990s provide a powerful case study of the way grey zone violence and violent non-state actor conflicts accelerate political collapse and destabilize the natural environment in ways that facilitate outbreaks of lethal infectious disease. There was a period of time in the 1990s when Liberia and Sierra Leone were both declared failed states, with no functional government and multiple warlord insurgencies competing for control of lucrative natural resources, including diamond mines and timber reserves.^21,48 Conflict zones eventually stabilized under the control of Charles Taylor's insurgency. Taylor continued to expand his territory until he gained control of a large forested region that included parts of Guinea, Liberia, and Sierra Leone. He renamed this space “Greater Liberia” and declared it to be sovereign territory under his personal control.^21,48

Greater Liberia eventually developed its own currency, transportation networks, and banking centers. This infrastructure, however, was developed for resource extraction rather than governance. One mining consortium, for instance, allegedly paid Taylor $10 million for access to deposits of iron ore and protected transportation routes. Other deals were brokered with logging companies to extract timber from virgin rainforest. ^48(p115) Because these transactions were arranged outside the control of a formally recognized government, there were no efforts to mitigate environmental destruction or protect the health of workers.

More than 100,000 Liberians (out of a population of 2.5 million) were killed in the violence of Taylor's 8-year rule. Many more were left mutilated and traumatized. Those who survived often did so by fleeing conflict zones and relocating to improvised slums in the capital city of Monrovia. These shanty towns were described by one reporter as places of “scant electricity and raging dysentery,” with an unemployment rate of nearly 90%. By the mid-1990s, almost half of Liberia's population had left the country, including many educated professionals and nearly all physicians.^50-52

Chaotic population movements in and out of warlord zones also put crowds of desperate refugees into close contact with one another, and with animal reservoirs of disease in a country undergoing rapid deforestation and chaotic urbanization in ungoverned spaces. The first indications of Ebola's emergence in West Africa actually date back to this time, when ethologists working in neighboring Ivory Coast found a number of dead chimpanzees in the Taï National Park. A few weeks after this discovery, a member of the research team became ill after conducting an autopsy on one of the chimpanzees. Serological tests were initially inconclusive, but virologists ultimately identified the human and chimpanzee illnesses as having been caused by a West African variant of Ebola fever with genetic similarities to Ebola Zaire. ⁵³

In 1995, a year after the chimpanzee deaths, a Liberian refugee sought treatment at a medical facility near the border with Ivory Coast. He was initially thought to be suffering from yellow fever, but blood tests revealed the presence of Ebola antibodies. He was described as “chief of a troop of 17 warriors, living generally in the bush,” who was presumably subsisting on hunted bushmeat and vulnerable to infection with the West African variant of Ebola circulating among primate populations. ⁵⁴ The New York Times initially reported that 4 additional Ebola patients were discovered in the man's home village in Liberia, all of whom had shared living space with the original case. ⁵⁵ But a later article published in Current Topics in Microbiology and Immunology stated that the second set of blood samples obtained in Liberia tested negative for Ebola. ⁵⁴

These vignettes suggest that Ebola fever may have been circulating at low levels in primate and human populations in warlord zones decades before it emerged as a global health threat in 2014. The World Health Organization, however, did not recognize the early warning signs that appeared in the 1990s. The agency's failure to anticipate Ebola's reemergence allowed the virus to spread rapidly during the first half of 2014, leading to thousands of deaths and a rapid escalation of global risk. ⁵⁶

Collapse and Regeneration: Corruption and Criminal States

Eventually Charles Taylor's warlord mini-state expanded across the entire territory of Liberia and became the new Liberian state. He was formally elected to the presidency in 1997 and remained in power until 2003. During this time, the disconnection between territory and sovereignty in Liberia resolved, but in a way that further increased the region's insecurity and vulnerability to emerging infectious disease. The government formed by Taylor extended the predatory institutions of warlord rule across the entire country. The result was a corrupt kleptocracy that engaged in wanton violence, looted the country's wealth, and provided few services to the population. Taylor redirected approximately $18 million per year from the Liberian maritime registry system to his personal bank accounts, and he used the funds to purchase weapons and engage in cross-border incursions to raid diamond mines in Sierra Leone. ⁵⁷ Taylor's institutionalized mechanisms of looting were so effective that, after his regime collapsed, Liberia was officially recognized as the poorest country in the world.

Since that time, Liberia has taken steps to restore its economy, strengthen its civic institutions, and train a new generation of health professionals and civil servants. But years of warlord governance left behind an entrenched legacy of infrastructure decline and public sector corruption that also hampered Ebola containment efforts. ⁵⁸ In 2013, Liberia still had only 51 physicians for a total population of more than 4 million people. ⁵⁹ In 2015, the General Accounting Commission of Liberia conducted an investigation into theft of Ebola funds and determined that approximately $15 million was “misused and abused by those tasked with the responsibility to oversee the fight against the virus.” ⁶⁰ Similar patterns of corruption and diversion of resources from the Ebola crises were reported in Sierra Leone. ⁶¹

Tajikistan

Tajikistan provides another example of a country that experienced prolonged health decline and resurgent outbreaks of disease following a period of political collapse, warlord rule, and regeneration of a criminal state. One of the destabilizing factors in Tajikistan has been the country's strategic position in the global narcotics trade. Over 80% of the world's opium is produced in Afghanistan and transported across Tajikistan to Russia and western Europe.^62,63 According to the United Nations, the total estimated dollar value of this trade is approximately US$13 billion per year. ⁶⁴ Tajikistan's entire gross domestic product in 2010, however, was only around US$10 billion. ⁶⁵ In other words, most of the country's wealth flows through the informal economy, where it corrodes the public sector and fuels insurgencies.

In the phase of collapse that followed the end of the USSR, multiple violent non-state actor insurgencies formed in Tajikistan and fought one another for monopoly control of the country's lucrative smuggling routes. For several years during the 1990s, there was no central government. Instead, rival warlords fought one another and levied predatory taxes on rural agrarian producers. One group briefly gained control of the country's largest metal smelter, further enriching themselves through illicit aluminum sales. ⁶⁶ The period of acute conflict ended with a peace deal in 1997, but elements of organized crime and warlordism remain embedded in the formal institutions of government. Tajikistan is consistently ranked as one of the most corrupt countries in the region, and government officials (including the diplomatic corps) have been caught smuggling heroin. In 2001, the secretary of Tajikistan's security council “acknowledged that many drug merchants and couriers are also representatives of Tajik state agencies.” ^62(p846) A few areas of the country still remain under the control of “rogue warlords” who operate competing smuggling operations. ⁶⁷

Tajikistan's phases of political collapse and post-state regeneration have been accompanied by health declines and resurgent epidemics of preventable disease. At the time of the Soviet collapse, Tajikistan had as many educated professionals, hospitals, and health facilities as countries in western Europe. ⁴⁴ At least 20% of the country's schools were destroyed during the violent non-state actor conflicts of the mid 1990s, and more than 1 million refugees fled the country, including many educated professionals. Contemporary observers describe health facilities as having “deteriorated sharply since … independence.” ⁶⁸ There has been minimal investment in new technologies or equipment since the Soviet era. ⁶⁸ Recent reports indicate that Tajikistan's infant mortality rate remains “among the highest in the WHO European region,” but accurate data are hard to come by. ^{68(p xv)} In 2010, only 45% of Tajikistan's births were registered, and several health surveys indicated significant regional variation in infant mortality, ranging from a low of 30 per 1,000 live births to as high as 70 to 80 per 1,000 live births. Mortality data are not accurately recorded on death certificates, further blurring the overall picture of Tajikistan's reported health trends. ^68(p13)

Tajikistan has also suffered epidemics of previously controlled diseases like malaria because of the erosion of public health prevention programs after the collapse of the USSR. An initial malaria outbreak was recorded in 1992, during a time of conflict between rival warlords. By 1997, nearly 30,000 cases were reported, but some estimates placed the total number of cases at 200,000 to 500,000. The morbidity rate for malaria was only 3.3 per 100,000 population in 1992, but increased to 512 per 100,000 after a decade of warlord conflict, institutional failures, corruption, and collapse. Refugees also exported malaria to neighboring Afghanistan, where it has become reestablished. ⁶⁸ Recent reports indicate great success in bringing malaria under control in Tajikistan. ⁶⁹ But the events of the 1990s suggest that public health successes should not be considered permanent in an environment of warlordism, political corruption, and instability. As long as Tajikistan's economy and political system remain corroded by revenues from the narcotics trade, health gains are likely to be short-lived.

Conclusions

The case studies presented here are intended to help public health scholars understand how political contraction and violent non-state actor insurgencies create invisible geographies of risk that threaten global health security. In Liberia, a decade of instability, warlord governance, deforestation, and political corruption combined to facilitate the emergence of a lethal new pathogen that created a public health crisis of international concern in 2014. In Tajikistan, the collapse of the USSR led to a phase of violent warlordism, instability, corruption, and resurgent outbreaks of preventable disease. In both of these examples, epidemics were amplified by the collapse of the public health sector, grey zone violence, and subsequent regeneration of a criminal state. In both cases, early efforts to contain outbreaks failed and the disease spread to neighboring regions. Ebola even expanded across continents to threaten populations in Europe and the United States.

Similar patterns of risk amplification can be found in other fragile states with areas under violent non-state actor control. Parts of Nigeria, for instance, are now expected to suffer severe famine because of the destruction of productive infrastructure by the insurgent group Boko Haram. ⁷⁰ Three million people have been displaced by this insurgency, and another 2 million remain inaccessible to aid workers because of ongoing security risks. According to a recent report by the Washington Post, the scale of this unfolding crises has remained hidden for years because the area is too dangerous for journalists to visit. ⁷¹ The Nigerian government has also been described as hindering relief efforts because of entrenched political corruption. ⁷¹ Any lethal pathogen—whether a novel virus or a deadly biowarfare agent—that emerges in a similar violent non-state actor–controlled space could potentially find a large number of vulnerable hosts before being recognized or reported to international health agencies.

Violent non-state actor risk zones are not visible in official country health reports, which by definition describe conditions in areas under government control. In some failing states, this may include only a small percentage of the population. A more proactive approach to health security requires the development of new metrics to assess the dynamics of grey zone territories and the risks faced by inhabitants of these areas. Country-level health reports are not adequate, since these data are generated and analyzed based on the assumption that political sovereignty extends across the entirety of mapped territory.

One simple metric for identifying epidemiologic risk zones in failing states can be developed by combining information from the Fund for Peace index of Fragile States and Transparency International's annual Corruption Perceptions Index. The Fund for Peace classifies all states into 10 categories of stability ranging from “very high alert” (meaning near collapse) to “very sustainable.”^72,73 The list is updated every year so that it is possible to track patterns over time. The Corruption Perceptions Index scores all countries on a scale from 1 to 100 based on various indicators of political corruption.⁷⁴ Cross-referencing these 2 indices creates a composite score that can be used to estimate the extent of a country's “ungoverned spaces” and vulnerability to epidemic infectious disease. Countries that score in the highest risk tier on both lists should be prioritized for increased epidemiologic surveillance in border areas and among refugee populations. Given the potential for terrorist groups to colonize grey zones, states with high fragility and corruption scores should also be considered at risk for potential release of weaponized pathogens from bioterrorism.

Whatever data sources are used, the most essential step in assessing the risks posed by failing states is to revise outdated 20th-century models of the state. Global events since the late 1990s reveal that states are not fixed or static political entities. They should be modeled as dynamic variables, with emergent properties that increase or decrease epidemiologic risks over time in a given region. Or to put it in ecological terms, the macro-level political contraction of a failed state creates an expanded niche for micro-level pathogens to exploit vulnerable human communities. The territorial contours of these niches will change over time, as failing states either collapse or regain control over turbulent peripheral regions. Cartographic maps remain static during these contests, but human populations and their microbial communities do not. Instead, geopolitical shifts at the macro level configure changes at the micro level that facilitate the emergence and spread of lethal infectious disease. Better understanding of these dynamics will result in improved predictive modeling of global health risks in the 21st century.