Jonathan Cohen and Joseph J Amon

The relationship between the health status of a population and the behavior of the government under which that population lives has been previously explored in war or civil crisis settings, and in the context of chronic health issues such as nutrition, famine, and child mortality (Sen, 1999; Dreze and Sen, 2002). These studies have found that government behavior (sometimes captured by the term "governance"), as measured by indicators such as accountability, stability, rule of law, respect for human rights, and the existence of an independent civil society, plays a significant role in health outcomes - a role independent of, and perhaps even superior to, host genetics, insect vectors, or individual behaviors. Famines stem not solely from bad weather or genetics, but also from the failure of governments to protect their populations from civil strife, or to equitably distribute food aid. Occupational illnesses, such as pneumoconiosis (or "black lung"), can be understood in terms of the risk behaviors and biological susceptibility of mineworkers, but also as a failure of governments to protect individuals in the workplace.

Despite the widespread acceptance of these findings, the influence of governance on infectious disease spread has received far less attention. As the chapters in this volume illustrate, there is an increasing appreciation that factors outside what is traditionally considered the health sphere can contribute to creating or controlling endemic and epidemic infectious disease. Some of these causes are socio-cultural, while others are the result of migrating populations, transportation

infrastructure, and the workforce. There is increasing evidence, from diverse infectious diseases and using diverse research approaches, that suggests that government behavior has an influence on infectious disease spread and control as well.

We begin this chapter by exploring the fundamental obligation of governments to protect health, drawing on both historical state practice and explicit obligations under international human rights law. We note that this obligation extends not only to the provision of health care or to the control of infectious disease outbreaks, but also to the cessation of human rights violations that contribute to poor health or disease risk. We then review recent attempts to quantify the relationship between good (or bad) governance and public health, noting that such quantification is often limited by confounding factors and methodological limitations. By reference to three infectious diseases - HIV and AIDS, Guinea Worm, and SARS -we explore some of the causal mechanisms by which human rights abuses might fuel disease spread and/or constrain the ability of governments to arrest disease. We conclude by reflecting on the importance of developing a coherent framework for understanding the precise relationship between governance, human rights, and infectious disease.

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