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Friday, November 1, 2019

Nuclear proliferation

From Wikipedia, the free encyclopedia
 
Nuclear proliferation is the spread of nuclear weapons, fissionable material, and weapons-applicable nuclear technology and information to nations not recognized as "Nuclear Weapon States" by the Treaty on the Non-Proliferation of Nuclear Weapons, commonly known as the Non-Proliferation Treaty or NPT. Proliferation has been opposed by many nations with and without nuclear weapons, as governments fear that more countries with nuclear weapons will increase the possibility of nuclear warfare (up to and including the so-called "countervalue" targeting of civilians with nuclear weapons), de-stabilize international or regional relations, or infringe upon the national sovereignty of states

Four countries besides the five recognized Nuclear Weapons States have acquired, or are presumed to have acquired, nuclear weapons: India, Pakistan, North Korea, and Israel. None of these four is a party to the NPT, although North Korea acceded to the NPT in 1985, then withdrew in 2003 and conducted announced nuclear tests in 2006, 2009, 2013, 2016, and 2017. One critique of the NPT is that the treaty is discriminatory in the sense that only those countries that tested nuclear weapons before 1968 are recognized as nuclear weapon states while all other states are treated as non-nuclear-weapon states who can only join the treaty if they forswear nuclear weapons.

Research into the development of nuclear weapons was initially undertaken during World War II by the United States (in cooperation with the United Kingdom and Canada), Germany, Japan, and the USSR. The United States was the first and is the only country to have used a nuclear weapon in war, when it used two bombs against Japan in August 1945. After surrendering to end the war, Germany and Japan ceased to be involved in any nuclear weapon research. In August 1949, the USSR tested a nuclear weapon, becoming the second country to detonate a nuclear bomb. The United Kingdom first tested a nuclear weapon in October 1952. France first tested a nuclear weapon in 1960. The People's Republic of China detonated a nuclear weapon in 1964. India conducted its first nuclear test in 1974, which prompted Pakistan to develop its own nuclear program and, when India conducted a second series of nuclear tests in 1998, Pakistan followed with a series of tests of its own. In 2006, North Korea conducted its first nuclear test.

Non-proliferation efforts

Early efforts to prevent nuclear proliferation involved intense government secrecy, the wartime acquisition of known uranium stores (the Combined Development Trust), and at times even outright sabotage—such as the bombing of a heavy-water facility thought to be used for a German nuclear program. These efforts began immediately after the discovery of nuclear fission and its military potential. None of these efforts were explicitly public, because the weapon developments themselves were kept secret until the bombing of Hiroshima

Earnest international efforts to promote nuclear non-proliferation began soon after World War II, when the Truman Administration proposed the Baruch Plan of 1946, named after Bernard Baruch, America's first representative to the United Nations Atomic Energy Commission. The Baruch Plan, which drew heavily from the Acheson–Lilienthal Report of 1946, proposed the verifiable dismantlement and destruction of the U.S. nuclear arsenal (which, at that time, was the only nuclear arsenal in the world) after all governments had cooperated successfully to accomplish two things: (1) the establishment of an "international atomic development authority," which would actually own and control all military-applicable nuclear materials and activities, and (2) the creation of a system of automatic sanctions, which not even the U.N. Security Council could veto, and which would proportionately punish states attempting to acquire the capability to make nuclear weapons or fissile material. 

Baruch's plea for the destruction of nuclear weapons invoked basic moral and religious intuitions. In one part of his address to the UN, Baruch said, "Behind the black portent of the new atomic age lies a hope which, seized upon with faith, can work out our salvation. If we fail, then we have damned every man to be the slave of Fear. Let us not deceive ourselves. We must elect World Peace or World Destruction.... We must answer the world's longing for peace and security." With this remark, Baruch helped launch the field of nuclear ethics, to which many policy experts and scholars have contributed.
Although the Baruch Plan enjoyed wide international support, it failed to emerge from the UNAEC because the Soviet Union planned to veto it in the Security Council. Still, it remained official American policy until 1953, when President Eisenhower made his "Atoms for Peace" proposal before the U.N. General Assembly. Eisenhower's proposal led eventually to the creation of the International Atomic Energy Agency (IAEA) in 1957. Under the "Atoms for Peace" program thousands of scientists from around the world were educated in nuclear science and then dispatched home, where many later pursued secret weapons programs in their home country.

Efforts to conclude an international agreement to limit the spread of nuclear weapons did not begin until the early 1960s, after four nations (the United States, the Soviet Union, the United Kingdom and France) had acquired nuclear weapons. Although these efforts stalled in the early 1960s, they renewed once again in 1964, after China detonated a nuclear weapon. In 1968, governments represented at the Eighteen Nation Disarmament Committee (ENDC) finished negotiations on the text of the NPT. In June 1968, the U.N. General Assembly endorsed the NPT with General Assembly Resolution 2373 (XXII), and in July 1968, the NPT opened for signature in Washington, DC, London and Moscow. The NPT entered into force in March 1970. 

Since the mid-1970s, the primary focus of non-proliferation efforts has been to maintain, and even increase, international control over the fissile material and specialized technologies necessary to build such devices because these are the most difficult and expensive parts of a nuclear weapons program. The main materials whose generation and distribution is controlled are highly enriched uranium and plutonium. Other than the acquisition of these special materials, the scientific and technical means for weapons construction to develop rudimentary, but working, nuclear explosive devices are considered to be within the reach of industrialized nations. 

Since its founding by the United Nations in 1957, the International Atomic Energy Agency (IAEA) has promoted two, sometimes contradictory, missions: on the one hand, the Agency seeks to promote and spread internationally the use of civilian nuclear energy; on the other hand, it seeks to prevent, or at least detect, the diversion of civilian nuclear energy to nuclear weapons, nuclear explosive devices or purposes unknown. The IAEA now operates a safeguards system as specified under Article III of the Nuclear Non-Proliferation Treaty (NPT) of 1968, which aims to ensure that civil stocks of uranium and plutonium, as well as facilities and technologies associated with these nuclear materials, are used only for peaceful purposes and do not contribute in any way to proliferation or nuclear weapons programs. It is often argued that proliferation of nuclear weapons to many other states has been prevented by the extension of assurances and mutual defence treaties to these states by nuclear powers, but other factors, such as national prestige, or specific historical experiences, also play a part in hastening or stopping nuclear proliferation.

Dual use technology

Dual-use technology refers to the possibility of military use of civilian nuclear power technology. Many technologies and materials associated with the creation of a nuclear power program have a dual-use capability, in that several stages of the nuclear fuel cycle allow diversion of nuclear materials for nuclear weapons. When this happens a nuclear power program can become a route leading to the atomic bomb or a public annex to a secret bomb program. The crisis over Iran’s nuclear activities is a case in point.

Many UN and US agencies warn that building more nuclear reactors unavoidably increases nuclear proliferation risks. A fundamental goal for American and global security is to minimize the proliferation risks associated with the expansion of nuclear power. If this development is "poorly managed or efforts to contain risks are unsuccessful, the nuclear future will be dangerous". For nuclear power programs to be developed and managed safely and securely, it is important that countries have domestic “good governance” characteristics that will encourage proper nuclear operations and management:
These characteristics include low degrees of corruption (to avoid officials selling materials and technology for their own personal gain as occurred with the A.Q. Khan smuggling network in Pakistan), high degrees of political stability (defined by the World Bank as “likelihood that the government will be destabilized or overthrown by unconstitutional or violent means, including politically-motivated violence and terrorism”), high governmental effectiveness scores (a World Bank aggregate measure of “the quality of the civil service and the degree of its independence from political pressures [and] the quality of policy formulation and implementation”), and a strong degree of regulatory competence.

International cooperation

Treaty on the Non-Proliferation of Nuclear Weapons

At present, 189 countries are States Parties to the Treaty on the Nonproliferation of Nuclear Weapons, more commonly known as the Nuclear Non-Proliferation Treaty or NPT. These include the five Nuclear Weapons States (NWS) recognized by the NPT: the People's Republic of China, France, Russian Federation, the UK, and the United States.

Notable non-signatories to the NPT are Israel, Pakistan, and India (the latter two have since tested nuclear weapons, while Israel is considered by most to be an unacknowledged nuclear weapons state). North Korea was once a signatory but withdrew in January 2003. The legality of North Korea's withdrawal is debatable but as of 9 October 2006, North Korea clearly possesses the capability to make a nuclear explosive device.

International Atomic Energy Agency

The IAEA was established on 29 July 1957 to help nations develop nuclear energy for peaceful purposes. Allied to this role is the administration of safeguards arrangements to provide assurance to the international community that individual countries are honoring their commitments under the treaty. Though established under its own international treaty, the IAEA reports to both the United Nations General Assembly and the Security Council

The IAEA regularly inspects civil nuclear facilities to verify the accuracy of documentation supplied to it. The agency checks inventories, and samples and analyzes materials. Safeguards are designed to deter diversion of nuclear material by increasing the risk of early detection. They are complemented by controls on the export of sensitive technology from countries such as UK and United States through voluntary bodies such as the Nuclear Suppliers Group. The main concern of the IAEA is that uranium not be enriched beyond what is necessary for commercial civil plants, and that plutonium which is produced by nuclear reactors not be refined into a form that would be suitable for bomb production.

Scope of safeguards

Traditional safeguards are arrangements to account for and control the use of nuclear materials. This verification is a key element in the international system which ensures that uranium in particular is used only for peaceful purposes. 

Parties to the NPT agree to accept technical safeguard measures applied by the IAEA. These require that operators of nuclear facilities maintain and declare detailed accounting records of all movements and transactions involving nuclear material. Over 550 facilities and several hundred other locations are subject to regular inspection, and their records and the nuclear material being audited. Inspections by the IAEA are complemented by other measures such as surveillance cameras and instrumentation.
The inspections act as an alert system providing a warning of the possible diversion of nuclear material from peaceful activities. The system relies on;
  1. Material Accountancy – tracking all inward and outward transfers and the flow of materials in any nuclear facility. This includes sampling and analysis of nuclear material, on-site inspections, and review and verification of operating records.
  2. Physical Security – restricting access to nuclear materials at the site.
  3. Containment and Surveillance – use of seals, automatic cameras and other instruments to detect unreported movement or tampering with nuclear materials, as well as spot checks on-site.
All NPT non-weapons states must accept these full-scope safeguards. In the five weapons states plus the non-NPT states (India, Pakistan and Israel), facility-specific safeguards apply. IAEA inspectors regularly visit these facilities to verify completeness and accuracy of records. 

The terms of the NPT cannot be enforced by the IAEA itself, nor can nations be forced to sign the treaty. In reality, as shown in Iraq and North Korea, safeguards can be backed up by diplomatic, political and economic measures. 

While traditional safeguards easily verified the correctness of formal declarations by suspect states, in the 1990s attention turned to what might not have been declared. While accepting safeguards at declared facilities, Iraq had set up elaborate equipment elsewhere in an attempt to enrich uranium to weapons grade. North Korea attempted to use research reactors (not commercial electricity-generating reactors) and a reprocessing plant to produce some weapons-grade plutonium. 

The weakness of the NPT regime lay in the fact that no obvious diversion of material was involved. The uranium used as fuel probably came from indigenous sources, and the nuclear facilities were built by the countries themselves without being declared or placed under safeguards. Iraq, as an NPT party, was obliged to declare all facilities but did not do so. Nevertheless, the activities were detected and brought under control using international diplomacy. In Iraq, a military defeat assisted this process. 

In North Korea, the activities concerned took place before the conclusion of its NPT safeguards agreement. With North Korea, the promised provision of commercial power reactors appeared to resolve the situation for a time, but it later withdrew from the NPT and declared it had nuclear weapons.

Additional Protocol

In 1993 a program was initiated to strengthen and extend the classical safeguards system, and a model protocol was agreed by the IAEA Board of Governors 1997. The measures boosted the IAEA's ability to detect undeclared nuclear activities, including those with no connection to the civil fuel cycle. 

Innovations were of two kinds. Some could be implemented on the basis of IAEA's existing legal authority through safeguards agreements and inspections. Others required further legal authority to be conferred through an Additional Protocol. This must be agreed by each non-weapons state with IAEA, as a supplement to any existing comprehensive safeguards agreement. Weapons states have agreed to accept the principles of the model additional protocol. 

Key elements of the model Additional Protocol:
  • The IAEA is to be given considerably more information on nuclear and nuclear-related activities, including R & D, production of uranium and thorium (regardless of whether it is traded), and nuclear-related imports and exports.
  • IAEA inspectors will have greater rights of access. This will include any suspect location, it can be at short notice (e.g., two hours), and the IAEA can deploy environmental sampling and remote monitoring techniques to detect illicit activities.
  • States must streamline administrative procedures so that IAEA inspectors get automatic visa renewal and can communicate more readily with IAEA headquarters.
  • Further evolution of safeguards is towards evaluation of each state, taking account of its particular situation and the kind of nuclear materials it has. This will involve greater judgement on the part of IAEA and the development of effective methodologies which reassure NPT States.
As of 3 July 2015, 146 countries have signed Additional Protocols and 126 have brought them into force. The IAEA is also applying the measures of the Additional Protocol in Taiwan. Under the Joint Comprehensive Plan of Action, Iran has agreed to implement its protocol provisionally. Among the leading countries that have not signed the Additional Protocol are Egypt, which says it will not sign until Israel accepts comprehensive IAEA safeguards, and Brazil, which opposes making the protocol a requirement for international cooperation on enrichment and reprocessing, but has not ruled out signing.

Limitations of safeguards

The greatest risk from nuclear weapons proliferation comes from countries which have not joined the NPT and which have significant unsafeguarded nuclear activities; India, Pakistan, and Israel fall within this category. While safeguards apply to some of their activities, others remain beyond scrutiny. 

A further concern is that countries may develop various sensitive nuclear fuel cycle facilities and research reactors under full safeguards and then subsequently opt out of the NPT. Bilateral agreements, such as insisted upon by Australia and Canada for sale of uranium, address this by including fallback provisions, but many countries are outside the scope of these agreements. If a nuclear-capable country does leave the NPT, it is likely to be reported by the IAEA to the UN Security Council, just as if it were in breach of its safeguards agreement. Trade sanctions would then be likely. 

IAEA safeguards can help ensure that uranium supplied as nuclear fuel and other nuclear supplies do not contribute to nuclear weapons proliferation. In fact, the worldwide application of those safeguards and the substantial world trade in uranium for nuclear electricity make the proliferation of nuclear weapons much less likely. 

The Additional Protocol, once it is widely in force, will provide credible assurance that there are no undeclared nuclear materials or activities in the states concerned. This will be a major step forward in preventing nuclear proliferation.

Other developments

The Nuclear Suppliers Group communicated its guidelines, essentially a set of export rules, to the IAEA in 1978. These were to ensure that transfers of nuclear material or equipment would not be diverted to unsafeguarded nuclear fuel cycle or nuclear explosive activities, and formal government assurances to this effect were required from recipients. The Guidelines also recognised the need for physical protection measures in the transfer of sensitive facilities, technology and weapons-usable materials, and strengthened retransfer provisions. The group began with seven members – the United States, the former USSR, the UK, France, Germany, Canada and Japan – but now includes 46 countries including all five nuclear weapons states

The International Framework for Nuclear Energy Cooperation is an international project involving 25 partner countries, 28 observer and candidate partner countries, and the International Atomic Energy Agency, the Generation IV International Forum, and the European Commission. Its goal is to "[..] provide competitive, commercially-based services as an alternative to a state’s development of costly, proliferation-sensitive facilities, and address other issues associated with the safe and secure management of used fuel and radioactive waste."

According to Kenneth D. Bergeron's Tritium on Ice: The Dangerous New Alliance of Nuclear Weapons and Nuclear Power, tritium is not classified as a "special nuclear material" but rather as a by-product. It is seen as an important litmus test on the seriousness of the United States' intention to nuclear disarm. This radioactive super-heavy hydrogen isotope is used to boost the efficiency of fissile materials in nuclear weapons. The United States resumed tritium production in 2003 for the first time in 15 years. This could indicate that there is a potential nuclear arm stockpile replacement since the isotope naturally decays

In May 1995, NPT parties reaffirmed their commitment to a Fissile Materials Cut-off Treaty to prohibit the production of any further fissile material for weapons. This aims to complement the Comprehensive Nuclear-Test-Ban Treaty of 1996 (not entered into force as of 2011) and to codify commitments made by the United States, the UK, France and Russia to cease production of weapons material, as well as putting a similar ban on China. This treaty will also put more pressure on Israel, India and Pakistan to agree to international verification.

On 9 August 2005, Ayatollah Ali Khamenei issued a fatwa forbidding the production, stockpiling and use of nuclear weapons. Khamenei's official statement was made at the meeting of the International Atomic Energy Agency (IAEA) in Vienna. As of February 2006 Iran formally announced that uranium enrichment within their borders has continued. Iran claims it is for peaceful purposes but the United Kingdom, France, Germany, and the United States claim the purpose is for nuclear weapons research and construction.

Unsanctioned nuclear activity

NPT Non Signatories

India, Pakistan and Israel have been "threshold" countries in terms of the international non-proliferation regime. They possess or are quickly capable of assembling one or more nuclear weapons. They have remained outside the 1970 NPT. They are thus largely excluded from trade in nuclear plant or materials, except for safety-related devices for a few safeguarded facilities.

In May 1998 India and Pakistan each exploded several nuclear devices underground. This heightened concerns regarding an arms race between them, with Pakistan involving the People's Republic of China, an acknowledged nuclear weapons state. Both countries are opposed to the NPT as it stands, and India has consistently attacked the Treaty since its inception in 1970 labeling it as a lopsided treaty in favor of the nuclear powers. 

Relations between the two countries are tense and hostile, and the risks of nuclear conflict between them have long been considered quite high. Kashmir is a prime cause of bilateral tension, its sovereignty being in dispute since 1948. There is persistent low level bilateral military conflict due to alleged backing of insurgency by Pakistan in India and infiltration of Pakistani state backed militants in the Indian state of Jammu and Kashmir, along with the disputed status of Kashmir. 

Both engaged in a conventional arms race in the 1980s, including sophisticated technology and equipment capable of delivering nuclear weapons. In the 1990s the arms race quickened. In 1994 India reversed a four-year trend of reduced allocations for defence, and despite its much smaller economy, Pakistan was expected to push its own expenditures yet higher. Both have lost their patrons: India, the former USSR, and Pakistan, the United States. 

Venn diagram displaying the historical proliferation among declared (solid circles) and undeclared nuclear weapon states (dashed circles). Number in parenthesis are the explosive nuclear tests conducted by a particular nation. The overlap between Russia and U.S. reflects the purchase by the U.S. Defense Special Weapons Agency.
 
But it is the growth and modernization of China's nuclear arsenal and its assistance with Pakistan's nuclear power programme and, reportedly, with missile technology, which exacerbate Indian concerns. In particular, as viewed by Indian strategists, Pakistan is aided by China's People's Liberation Army.

India

Nuclear power for civil use is well established in India. Its civil nuclear strategy has been directed towards complete independence in the nuclear fuel cycle, necessary because of its outspoken rejection of the NPT. Due to economic and technological isolation of India after the nuclear tests in 1974, India has largely diverted focus on developing and perfecting the fast breeder technology by intensive materials and fuel cycle research at the dedicated center established for research into fast reactor technology, Indira Gandhi Center for Atomic Research (IGCAR) at Kalpakkam, in the southern part of the country. At the moment, India has a small fast breeder reactor and is planning a much larger one (Prototype Fast Breeder Reactor). This self-sufficiency extends from uranium exploration and mining through fuel fabrication, heavy water production, reactor design and construction, to reprocessing and waste management. It is also developing technology to utilise its abundant resources of thorium as a nuclear fuel. 

India has 14 small nuclear power reactors in commercial operation, two larger ones under construction, and ten more planned. The 14 operating ones (2548 MWe total) comprise:
  • two 150 MWe BWRs from the United States, which started up in 1969, now use locally enriched uranium and are under safeguards,
  • two small Canadian PHWRs (1972 & 1980), also under safeguards, and
  • ten local PHWRs based on Canadian designs, two of 150 and eight 200 MWe.
  • two new 540 MWe and two 700 MWe plants at Tarapur (known as TAPP: Tarapur Atomic Power Station)
The two under construction and two of the planned ones are 450 MWe versions of these 200 MWe domestic products. Construction has been seriously delayed by financial and technical problems. In 2001 a final agreement was signed with Russia for the country's first large nuclear power plant, comprising two VVER-1000 reactors, under a Russian-financed US$3 billion contract. The first unit is due to be commissioned in 2007. A further two Russian units are under consideration for the site. Nuclear power supplied 3.1% of India's electricity in 2000. 

Its weapons material appears to come from a Canadian-designed 40 MW "research" reactor which started up in 1960, well before the NPT, and a 100 MW indigenous unit in operation since 1985. Both use local uranium, as India does not import any nuclear fuel. It is estimated that India may have built up enough weapons-grade plutonium for a hundred nuclear warheads. 

It is widely believed that the nuclear programs of India and Pakistan used CANDU reactors to produce fissionable materials for their weapons; however, this is not accurate. Both Canada (by supplying the 40 MW research reactor) and the United States (by supplying 21 tons of heavy water) supplied India with the technology necessary to create a nuclear weapons program, dubbed CIRUS (Canada-India Reactor, United States). Canada sold India the reactor on the condition that the reactor and any by-products would be "employed for peaceful purposes only.". Similarly, the United States sold India heavy water for use in the reactor "only... in connection with research into and the use of atomic energy for peaceful purposes". India, in violation of these agreements, used the Canadian-supplied reactor and American-supplied heavy water to produce plutonium for their first nuclear explosion, Smiling Buddha. The Indian government controversially justified this, however, by claiming that Smiling Buddha was a "peaceful nuclear explosion." 

The country has at least three other research reactors including the tiny one which is exploring the use of thorium as a nuclear fuel, by breeding fissile U-233. In addition, an advanced heavy-water thorium cycle is under development.

India exploded a nuclear device in 1974, the so-called Smiling Buddha test, which it has consistently claimed was for peaceful purposes. Others saw it as a response to China's nuclear weapons capability. It was then universally perceived, notwithstanding official denials, to possess, or to be able to quickly assemble, nuclear weapons. In 1999 it deployed its own medium-range missile and has developed an intermediate-range missile capable of reaching targets in China's industrial heartland. 

In 1995 the United States quietly intervened to head off a proposed nuclear test. However, in 1998 there were five more tests in Operation Shakti. These were unambiguously military, including one claimed to be of a sophisticated thermonuclear device, and their declared purpose was "to help in the design of nuclear weapons of different yields and different delivery systems".
Indian security policies are driven by:
  • its determination to be recognized as a dominant power in the region
  • its increasing concern with China's expanding nuclear weapons and missile delivery programmes
  • its concern with Pakistan's capability to deliver nuclear weapons deep into India
It perceives nuclear weapons as a cost-effective political counter to China's nuclear and conventional weaponry, and the effects of its nuclear weapons policy in provoking Pakistan is, by some accounts, considered incidental. India has had an unhappy relationship with China. After an uneasy ceasefire ended the 1962 war, relations between the two nations were frozen until 1998. Since then a degree of high-level contact has been established and a few elementary confidence-building measures put in place. China still occupies some territory which it captured during the aforementioned war, claimed by India, and India still occupies some territory claimed by China. Its nuclear weapon and missile support for Pakistan is a major bone of contention. 

American President George W. Bush met with India Prime Minister Manmohan Singh to discuss India's involvement with nuclear weapons. The two countries agreed that the United States would give nuclear power assistance to India.

Pakistan

In 2003, Libya admitted that the nuclear weapons-related material including these centrifuges, known as Pak-1, were acquired from Pakistan
 
Over the several years, the Nuclear power infrastructure has been well established by Pakistan which is dedicated for the industrial and economic development of the country. Its current nuclear policy is directed and aimed to promote the socio-economic development of the people as a "foremost priority"; and to fulfill the energy, economic, and industrial needs from the nuclear sources. Currently, there are three operational mega-commercial nuclear power plants while three larger ones are under construction. The nuclear power supplies 787 MW (roughly ≈ 3.6%) of electricity as of 2012, and the country has projected to produce 8800 MW electricity by 2030. Infrastructure established by the IAEA and the U.S. in the 1950s–1960s were based on peaceful research and development and economic prosperity of the country.

Although the civil-sector nuclear power was established in the 1950s, the country has an active nuclear weapons program which was started in the 1970s. The bomb program has its roots after East-Pakistan gained its independence as Bangladesh after India's successful intervention led to a decisive victory on Pakistan in 1971. This large-scale but clandestine atomic bomb project was directed towards the development of ingenious development of reactor and military-grade plutonium. In 1974, when India surprised the outer world with its successful detonation of its own bomb, codename Smiling Buddha, it became "imperative for Pakistan" to pursue the weapons research. According to leading scientist in the program, it became clear once India detonated the bomb, "Newton's third law" came into "operation", from then on it was a classic case of "action and reaction". Earlier efforts were directed towards mastering the plutonium technology from France, but plutonium route was partially slowed down when the plan was failed after the U.S. intervention to cancel the project. Contrary to popular perception, Pakistan did not forego the "plutonium" route and covertly continued its indegenious research under Munir Khan and it succeeded with plutonium route in the early 1980s. Reacting on India's nuclear test (Smiling Buddha), Bhutto and the country's elite political and military science circle sensed this test as final and dangerous anticipation to Pakistan's "moral and physical existence." With Aziz Ahmed on his side, Bhutto launched a serious diplomatic offense and aggressively maintained at the session of the United Nations Security Council:
Pakistan was exposed to a kind of "nuclear threat and blackmail" unparalleled elsewhere. ... If the world's community failed to provide political insurance to Pakistan and other countries against the nuclear blackmail, these countries would be constraint to launch atomic bomb programs of their own! ... [A]ssurances provided by the United Nations were not "Enough!"... 
— Zulfikar Ali Bhutto, statement written in "Eating Grass", source
After 1974, Bhutto's government redoubled its effort, this time equally focused on uranium and plutonium. Pakistan had established science directorates in almost all of her embassies in the important countries of the world, with theoretical physicist S.A. Butt being the director. Abdul Qadeer Khan then established a network through Dubai to smuggle URENCO technology to Engineering Research Laboratories. Earlier, he worked with Physics Dynamics Research Laboratories (FDO), a subsidiary of the Dutch firm VMF-Stork based in Amsterdam. Later after joining, the Urenco, he had access through photographs and documents of the technology. Against the popular perception, the technology that A.Q. Khan had brought from Urenco was based on first generation civil rector technology, filled with many serious technical errors, though it was authentic and vital link for centrifuge project of the country. After the British Government stopped the British subsidiary of the American Emerson Electric Co. from shipping the components to Pakistan, he describes his frustration with a supplier from Germany as: "That man from the German team was unethical. When he did not get the order from us, he wrote a letter to a Labour Party member and questions were asked in [British] Parliament." By 1978, his efforts were paid off and made him into a national hero. In 1981, as a tribute, President General Muhammad Zia-ul-Haq, renamed the research institute after his name.

In early 1996, Prime minister Benazir Bhutto made it clear that "if India conducts a nuclear test, Pakistan could be forced to "follow suit". In 1997, her statement was echoed by Prime minister Nawaz Sharif who maintained to the fact that "since 1972, [P]akistan had progressed significantly, and we have left that stage (developmental) far behind. Pakistan will not be made a "hostage" to India by signing the CTBT, before (India).!" In May 1998, within weeks of India's nuclear tests, Pakistan announced that it had conducted six underground tests in the Chagai Hills, five on the 28th and one on the 30th of that month. Seismic events consistent with these claims were recorded.

In 2004, the revelation of A.Q. Khan's efforts led to the exposure of many defunct European consortiums which had defied export restrictions in the 1970s, and of many defunct Dutch companies that exported thousands of centrifuges to Pakistan as early as 1976. Many centrifuge components were apparently manufactured in Malaysian Scomi Precision Engineering with the assistance of South Asian and German companies, and used a UAE-based computer company as a false front.

It was widely believed to have direct involvement of the government of Pakistan. This claim could not be verified due to the refusal of the government of Pakistan to allow IAEA to interview the alleged head of the nuclear black market, who happened to be no other than A.Q. Khan. Confessing his crimes later a month on national television, he bailed out the government by taking full responsibility. Independent investigation conducted by IISS confirmed that he had control over the import-export deals, and his acquisition activities were largely unsupervised by Pakistan governmental authorities. All of his activities went undetected for several years. He duly confessed of running the atomic proliferation ring from Pakistan to Iran and North Korea. He was immediately given presidential immunity. Exact nature of the involvement at the governmental level is still unclear, but the manner in which the government acted cast doubt on the sincerity of Pakistan.

North Korea

The Democratic People's Republic of Korea (or better known as North Korea), joined the NPT in 1985 and had subsequently signed a safeguards agreement with the IAEA. However, it was believed that North Korea was diverting plutonium extracted from the fuel of its reactor at Yongbyon, for use in nuclear weapons. The subsequent confrontation with IAEA on the issue of inspections and suspected violations, resulted in North Korea threatening to withdraw from the NPT in 1993. This eventually led to negotiations with the United States resulting in the Agreed Framework of 1994, which provided for IAEA safeguards being applied to its reactors and spent fuel rods. These spent fuel rods were sealed in canisters by the United States to prevent North Korea from extracting plutonium from them. North Korea had to therefore freeze its plutonium programme.

During this period, Pakistan-North Korea cooperation in missile technology transfer was being established. A high level delegation of Pakistan military visited North Korea in August–September 1992, reportedly to discuss the supply of missile technology to Pakistan. In 1993, PM Benazir Bhutto repeatedly traveled to China, and the paid state visit to North Korea. The visits are believed to be related to the subsequent acquisition technology to developed its Ghauri system by Pakistan. During the period 1992–1994, A.Q. Khan was reported to have visited North Korea thirteen times. The missile cooperation program with North Korea was under Dr. A. Q. Khan Research Laboratories. At this time China was under U.S. pressure not to supply the M Dongfeng series of missiles to Pakistan. It is believed by experts that possibly with Chinese connivance and facilitation, the latter was forced to approach North Korea for missile transfers. Reports indicate that North Korea was willing to supply missile sub-systems including rocket motors, inertial guidance systems, control and testing equipment for US$50 million.

It is not clear what North Korea got in return. Joseph S. Bermudez Jr. in Jane's Defence Weekly (27 November 2002) reports that Western analysts had begun to question what North Korea received in payment for the missiles; many suspected it was the nuclear technology. The KRL was in charge of both uranium program and also of the missile program with North Korea. It is therefore likely during this period that cooperation in nuclear technology between Pakistan and North Korea was initiated. Western intelligence agencies began to notice exchange of personnel, technology and components between KRL and entities of the North Korean 2nd Economic Committee (responsible for weapons production). 

A New York Times report on 18 October 2002 quoted U.S. intelligence officials having stated that Pakistan was a major supplier of critical equipment to North Korea. The report added that equipment such as gas centrifuges appeared to have been "part of a barter deal" in which North Korea supplied Pakistan with missiles. Separate reports indicate (The Washington Times, 22 November 2002) that U.S. intelligence had as early as 1999 picked up signs that North Korea was continuing to develop nuclear arms. Other reports also indicate that North Korea had been working covertly to develop an enrichment capability for nuclear weapons for at least five years and had used technology obtained from Pakistan (The Washington Times, 18 October 2002).

Israel

Israel is also thought to possess an arsenal of potentially up to several hundred nuclear warheads based on estimates of the amount of fissile material produced by Israel. This has never been openly confirmed or denied however, due to Israel's policy of deliberate ambiguity.

An Israeli nuclear installation is located about ten kilometers to the south of Dimona, the Negev Nuclear Research Center. Its construction commenced in 1958, with French assistance. The official reason given by the Israeli and French governments was to build a nuclear reactor to power a "desalination plant", in order to "green the Negev". The purpose of the Dimona plant is widely assumed to be the manufacturing of nuclear weapons, and the majority of defense experts have concluded that it does in fact do that. However, the Israeli government refuses to confirm or deny this publicly, a policy it refers to as "ambiguity". 

Norway sold 20 tonnes of heavy water needed for the reactor to Israel in 1959 and 1960 in a secret deal. There were no "safeguards" required in this deal to prevent usage of the heavy water for non-peaceful purposes. The British newspaper Daily Express accused Israel of working on a bomb in 1960. When the United States intelligence community discovered the purpose of the Dimona plant in the early 1960s, it demanded that Israel agree to international inspections. Israel agreed, but on a condition that U.S., rather than IAEA, inspectors were used, and that Israel would receive advanced notice of all inspections.

Some claim that because Israel knew the schedule of the inspectors' visits, it was able to hide the alleged purpose of the site from the inspectors by installing temporary false walls and other devices before each inspection. The inspectors eventually informed the U.S. government that their inspections were useless due to Israeli restrictions on what areas of the facility they could inspect. In 1969, the United States terminated the inspections. 

In 1986, Mordechai Vanunu, a former technician at the Dimona plant, revealed to the media some evidence of Israel's nuclear program. Israeli agents arrested him from Italy, drugged him and transported him to Israel, and an Israeli court then tried him in secret on charges of treason and espionage, and sentenced him to eighteen years imprisonment. He was freed on 21 April 2004, but was severely limited by the Israeli government. He was arrested again on 11 November 2004, though formal charges were not immediately filed.

Comments on photographs taken by Mordechai Vanunu inside the Negev Nuclear Research Center have been made by prominent scientists. British nuclear weapons scientist Frank Barnaby, who questioned Vanunu over several days, estimated Israel had enough plutonium for about 150 weapons.

According to Lieutenant Colonel Warner D. Farr in a report to the USAF Counterproliferation Center while France was previously a leader in nuclear research "Israel and France were at a similar level of expertise after WWII, and Israeli scientists could make significant contributions to the French effort." In 1986 Francis Perrin, French high-commissioner for atomic energy from 1951 to 1970 stated that in 1949 Israeli scientists were invited to the Saclay nuclear research facility, this cooperation leading to a joint effort including sharing of knowledge between French and Israeli scientists especially those with knowledge from the Manhattan Project.

Nuclear arms control in South Asia

The public stance of the two states on non-proliferation differs markedly. Pakistan has initiated a series of regional security proposals. It has repeatedly proposed a nuclear free zone in South Asia and has proclaimed its willingness to engage in nuclear disarmament and to sign the Non-Proliferation Treaty if India would do so. It has endorsed a United States proposal for a regional five power conference to consider non-proliferation in South Asia.

India has taken the view that solutions to regional security issues should be found at the international rather than the regional level, since its chief concern is with China. It therefore rejects Pakistan's proposals.

Instead, the 'Gandhi Plan', put forward in 1988, proposed the revision of the Non-Proliferation Treaty, which it regards as inherently discriminatory in favor of the nuclear-weapon States, and a timetable for complete nuclear weapons disarmament. It endorsed early proposals for a Comprehensive Test Ban Treaty and for an international convention to ban the production of highly enriched uranium and plutonium for weapons purposes, known as the 'cut-off' convention.

The United States for some years, especially under the Clinton administration, pursued a variety of initiatives to persuade India and Pakistan to abandon their nuclear weapons programs and to accept comprehensive international safeguards on all their nuclear activities. To this end, the Clinton administration proposed a conference of the five nuclear-weapon states, Japan, Germany, India and Pakistan.

India refused this and similar previous proposals, and countered with demands that other potential weapons states, such as Iran and North Korea, should be invited, and that regional limitations would only be acceptable if they were accepted equally by China. The United States would not accept the participation of Iran and North Korea and these initiatives have lapsed.

Another, more recent approach, centers on 'capping' the production of fissile material for weapons purposes, which would hopefully be followed by 'roll back'. To this end, India and the United States jointly sponsored a UN General Assembly resolution in 1993 calling for negotiations for a 'cut-off' convention. Should India and Pakistan join such a convention, they would have to agree to halt the production of fissile materials for weapons and to accept international verification on their relevant nuclear facilities (enrichment and reprocessing plants). It appears that India is now prepared to join negotiations regarding such a Cut-off Treaty, under the UN Conference on Disarmament.

Bilateral confidence-building measures between India and Pakistan to reduce the prospects of confrontation have been limited. In 1990 each side ratified a treaty not to attack the other's nuclear installations, and at the end of 1991 they provided one another with a list showing the location of all their nuclear plants, even though the respective lists were regarded as not being wholly accurate. Early in 1994 India proposed a bilateral agreement for a 'no first use' of nuclear weapons and an extension of the 'no attack' treaty to cover civilian and industrial targets as well as nuclear installations.

Having promoted the Comprehensive Test Ban Treaty since 1954, India dropped its support in 1995 and in 1996 attempted to block the Treaty. Following the 1998 tests the question has been reopened and both Pakistan and India have indicated their intention to sign the CTBT. Indian ratification may be conditional upon the five weapons states agreeing to specific reductions in nuclear arsenals. The UN Conference on Disarmament has also called upon both countries "to accede without delay to the Non-Proliferation Treaty", presumably as non-weapons states.

NPT signatories

Egypt

In 2004 and 2005, Egypt disclosed past undeclared nuclear activities and material to the IAEA. In 2007 and 2008, high enriched and low enriched uranium particles were found in environmental samples taken in Egypt. In 2008, the IAEA states Egypt's statements were consistent with its own findings. In May 2009, Reuters reported that the IAEA was conducting further investigation in Egypt.

Iran

In 2003, the IAEA reported that Iran had been in breach of its obligations to comply with provisions of its safeguard agreement. In 2005, the IAEA Board of Governors voted in a rare non-consensus decision to find Iran in non-compliance with its NPT Safeguards Agreement and to report that non-compliance to the UN Security Council. In response, the UN Security Council passed a series of resolutions citing concerns about the program. Iran's representative to the UN argues sanctions compel Iran to abandon its rights under the Nuclear Nonproliferation Treaty to peaceful nuclear technology. Iran says its uranium enrichment program is exclusively for peaceful purposes and has enriched uranium to "less than 5 percent," consistent with fuel for a nuclear power plant and significantly below the purity of WEU (around 90%) typically used in a weapons program. The director general of the International Atomic Energy Agency, Yukiya Amano, said in 2009 he had not seen any evidence in IAEA official documents that Iran was developing nuclear weapons.

Iraq

Up to the late 1980s it was generally assumed that any undeclared nuclear activities would have to be based on the diversion of nuclear material from safeguards. States acknowledged the possibility of nuclear activities entirely separate from those covered by safeguards, but it was assumed they would be detected by national intelligence activities. There was no particular effort by IAEA to attempt to detect them. 

Iraq had been making efforts to secure a nuclear potential since the 1960s. In the late 1970s a specialised plant, Osiraq, was constructed near Baghdad. The plant was attacked during the Iran–Iraq War and was destroyed by Israeli bombers in June 1981. 

Not until the 1990 NPT Review Conference did some states raise the possibility of making more use of (for example) provisions for "special inspections" in existing NPT Safeguards Agreements. Special inspections can be undertaken at locations other than those where safeguards routinely apply, if there is reason to believe there may be undeclared material or activities.

After inspections in Iraq following the UN Gulf War cease-fire resolution showed the extent of Iraq's clandestine nuclear weapons program, it became clear that the IAEA would have to broaden the scope of its activities. Iraq was an NPT Party, and had thus agreed to place all its nuclear material under IAEA safeguards. But the inspections revealed that it had been pursuing an extensive clandestine uranium enrichment programme, as well as a nuclear weapons design programme.

The main thrust of Iraq's uranium enrichment program was the development of technology for electromagnetic isotope separation (EMIS) of indigenous uranium. This uses the same principles as a mass spectrometer (albeit on a much larger scale). Ions of uranium-238 and uranium-235 are separated because they describe arcs of different radii when they move through a magnetic field. This process was used in the Manhattan Project to make the highly enriched uranium used in the Hiroshima bomb, but was abandoned soon afterwards.

The Iraqis did the basic research work at their nuclear research establishment at Tuwaitha, near Baghdad, and were building two full-scale facilities at Tarmiya and Ash Sharqat, north of Baghdad. However, when the war broke out, only a few separators had been installed at Tarmiya, and none at Ash Sharqat.

The Iraqis were also very interested in centrifuge enrichment, and had been able to acquire some components including some carbon-fibre rotors, which they were at an early stage of testing. In May 1998, Newsweek reported that Abdul Qadeer Khan had sent Iraq centrifuge designs, which were apparently confiscated by the UNMOVIC officials. Iraqi officials said "the documents were authentic but that they had not agreed to work with A. Q. Khan, fearing an ISI sting operation, due to strained relations between two countries. The Government of Pakistan and A. Q. Khan strongly denied this allegation whilst the government declared the evidence to be "fraudulent".

They were clearly in violation of their NPT and safeguards obligations, and the IAEA Board of Governors ruled to that effect. The UN Security Council then ordered the IAEA to remove, destroy or render harmless Iraq's nuclear weapons capability. This was done by mid-1998, but Iraq then ceased all cooperation with the UN, so the IAEA withdrew from this work. 

The revelations from Iraq provided the impetus for a very far-reaching reconsideration of what safeguards are intended to achieve.
Libya possesses ballistic missiles and previously pursued nuclear weapons under the leadership of Muammar Gaddafi. On 19 December 2003, Gaddafi announced that Libya would voluntarily eliminate all materials, equipment and programs that could lead to internationally proscribed weapons, including weapons of mass destruction and long-range ballistic missiles. Libya signed the Nuclear Non-Proliferation Treaty (NPT) in 1968 and ratified it in 1975, and concluded a safeguards agreement with the International Atomic Energy Agency (IAEA) in 1980. In March 2004, the IAEA Board of Governors welcomed Libya's decision to eliminate its formerly undeclared nuclear program, which it found had violated Libya's safeguards agreement, and approved Libya's Additional Protocol. The United States and the United Kingdom assisted Libya in removing equipment and material from its nuclear weapons program, with independent verification by the IAEA.

Myanmar

A report in the Sydney Morning Herald and Searchina, a Japanese newspaper, report that two Myanma defectors saying that the Myanmar junta was secretly building a nuclear reactor and plutonium extraction facility with North Korea's help, with the aim of acquiring its first nuclear bomb in five years. According to the report, "The secret complex, much of it in caves tunnelled into a mountain at Naung Laing in northern Burma, runs parallel to a civilian reactor being built at another site by Russia that both the Russians and Burmese say will be put under international safeguards." In 2002, Myanmar had notified IAEA of its intention to pursue a civilian nuclear programme. Later, Russia announced that it would build a nuclear reactor in Myanmar. There have also been reports that two Pakistani scientists, from the AQ Khan stable, had been dispatched to Myanmar where they had settled down, to help Myanmar's project. Recently, the David Albright-led Institute for Science and International Security (ISIS) rang alarm bells about Myanmar attempting a nuclear project with North Korean help. If true, the full weight of international pressure will be brought against Myanmar, said officials familiar with developments. But equally, the information that has been peddled by the defectors is also "preliminary" and could be used by the west to turn the screws on Myanmar—on democracy and human rights issues—in the run-up to the elections in the country in 2010. During an ASEAN meeting in Thailand in July 2009, US secretary of state Hillary Clinton highlighted concerns of the North Korean link. "We know there are also growing concerns about military cooperation between North Korea and Burma which we take very seriously," Clinton said. However, in 2012, after contact with the American president, Barack Obama, the Burmese leader, Thein Sein, renounced military ties with DPRK (North Korea).

North Korea

The Democratic People's Republic of Korea (DPRK) acceded to the NPT in 1985 as a condition for the supply of a nuclear power station by the USSR. However, it delayed concluding its NPT Safeguards Agreement with the IAEA, a process which should take only 18 months, until April 1992.
During that period, it brought into operation a small gas-cooled, graphite-moderated, natural-uranium (metal) fuelled "Experimental Power Reactor" of about 25 MWt (5 MWe), based on the UK Magnox design. While this was a well-suited design to start a wholly indigenous nuclear reactor development, it also exhibited all the features of a small plutonium production reactor for weapons purposes. North Korea also made substantial progress in the construction of two larger reactors designed on the same principles, a prototype of about 200 MWt (50 MWe), and a full-scale version of about 800 MWt (200 MWe). They made only slow progress; construction halted on both in 1994 and has not resumed. Both reactors have degraded considerably since that time and would take significant efforts to refurbish.

In addition it completed and commissioned a reprocessing plant that makes the Magnox spent nuclear fuel safe, recovering uranium and plutonium. That plutonium, if the fuel was only irradiated to a very low burn-up, would have been in a form very suitable for weapons. Although all these facilities at Yongbyon were to be under safeguards, there was always the risk that at some stage, the DPRK would withdraw from the NPT and use the plutonium for weapons. 

One of the first steps in applying NPT safeguards is for the IAEA to verify the initial stocks of uranium and plutonium to ensure that all the nuclear materials in the country have been declared for safeguards purposes. While undertaking this work in 1992, IAEA inspectors found discrepancies which indicated that the reprocessing plant had been used more often than the DPRK had declared, which suggested that the DPRK could have weapons-grade plutonium which it had not declared to the IAEA. Information passed to the IAEA by a Member State (as required by the IAEA) supported that suggestion by indicating that the DPRK had two undeclared waste or other storage sites. 

In February 1993 the IAEA called on the DPRK to allow special inspections of the two sites so that the initial stocks of nuclear material could be verified. The DPRK refused, and on 12 March announced its intention to withdraw from the NPT (three months' notice is required). In April 1993 the IAEA Board concluded that the DPRK was in non-compliance with its safeguards obligations and reported the matter to the UN Security Council. In June 1993 the DPRK announced that it had "suspended" its withdrawal from the NPT, but subsequently claimed a "special status" with respect to its safeguards obligations. This was rejected by IAEA.

Once the DPRK's non-compliance had been reported to the UN Security Council, the essential part of the IAEA's mission had been completed. Inspections in the DPRK continued, although inspectors were increasingly hampered in what they were permitted to do by the DPRK's claim of a "special status". However, some 8,000 corroding fuel rods associated with the experimental reactor have remained under close surveillance. 

Following bilateral negotiations between the United States and the DPRK, and the conclusion of the Agreed Framework in October 1994, the IAEA has been given additional responsibilities. The agreement requires a freeze on the operation and construction of the DPRK's plutonium production reactors and their related facilities, and the IAEA is responsible for monitoring the freeze until the facilities are eventually dismantled. The DPRK remains uncooperative with the IAEA verification work and has yet to comply with its safeguards agreement.

While Iraq was defeated in a war, allowing the UN the opportunity to seek out and destroy its nuclear weapons programme as part of the cease-fire conditions, the DPRK was not defeated, nor was it vulnerable to other measures, such as trade sanctions. It can scarcely afford to import anything, and sanctions on vital commodities, such as oil, would either be ineffective or risk provoking war.

Ultimately, the DPRK was persuaded to stop what appeared to be its nuclear weapons programme in exchange, under the agreed framework, for about US$5 billion in energy-related assistance. This included two 1000 MWe light water nuclear power reactors based on an advanced U.S. System-80 design. 

In January 2003 the DPRK withdrew from the NPT. In response, a series of discussions among the DPRK, the United States, and China, a series of six-party talks (the parties being the DPRK, the ROK, China, Japan, the United States and Russia) were held in Beijing; the first beginning in April 2004 concerning North Korea's weapons program.

On 10 January 2005, North Korea declared that it was in the possession of nuclear weapons. On 19 September 2005, the fourth round of the Six-Party Talks ended with a joint statement in which North Korea agreed to end its nuclear programs and return to the NPT in exchange for diplomatic, energy and economic assistance. However, by the end of 2005 the DPRK had halted all six-party talks because the United States froze certain DPRK international financial assets such as those in a bank in Macau.

On 9 October 2006, North Korea announced that it has performed its first-ever nuclear weapon test. On 18 December 2006, the six-party talks finally resumed. On 13 February 2007, the parties announced "Initial Actions" to implement the 2005 joint statement including shutdown and disablement of North Korean nuclear facilities in exchange for energy assistance. Reacting to UN sanctions imposed after missile tests in April 2009, North Korea withdrew from the six-party talks, restarted its nuclear facilities and conducted a second nuclear test on 25 May 2009.

On 12 February 2013, North Korea conducted an underground nuclear explosion with an estimated yield of 6 to 7 kilotonnes. The detonation registered a magnitude 4.9 disturbance in the area around the epicenter.

Russia

Security of nuclear weapons in Russia remains a matter of concern. According to high-ranking Russian SVR defector Tretyakov, he had a meeting with two Russian businessman representing a state-created C-W corporation in 1991. They came up with a project of destroying large quantities of chemical wastes collected from Western countries at the island of Novaya Zemlya (a test place for Soviet nuclear weapons) using an underground nuclear blast. The project was rejected by Canadian representatives, but one of the businessmen told Tretyakov that he keeps his own nuclear bomb at his dacha outside Moscow. Tretyakov thought that man was insane, but the "businessmen" (Vladimir K. Dmitriev) replied: "Do not be so naive. With economic conditions the way they are in Russia today, anyone with enough money can buy a nuclear bomb. It's no big deal really".

South Africa

In 1991, South Africa acceded to the NPT, concluded a comprehensive safeguards agreement with the IAEA, and submitted a report on its nuclear material subject to safeguards. At the time, the state had a nuclear power programme producing nearly 10% of the country's electricity, whereas Iraq and North Korea only had research reactors.

The IAEA's initial verification task was complicated by South Africa's announcement that between 1979 and 1989 it built and then dismantled a number of nuclear weapons. South Africa asked the IAEA to verify the conclusion of its weapons programme. In 1995 the IAEA declared that it was satisfied all materials were accounted for and the weapons programme had been terminated and dismantled.

South Africa has signed the NPT, and now holds the distinction of being the only known state to have indigenously produced nuclear weapons, and then verifiably dismantled them.

Syria

On 6 September 2007, Israel bombed an officially unidentified site in Syria which it later asserted was a nuclear reactor under construction. The alleged reactor was not asserted to be operational and it was not asserted that nuclear material had been introduced into it. Syria said the site was a military site and was not involved in any nuclear activities. The IAEA requested Syria to provide further access to the site and any other locations where the debris and equipment from the building had been stored. Syria denounced what it called the Western "fabrication and forging of facts" in regards to the incident. IAEA Director General Mohamed ElBaradei criticized the strikes and deplored that information regarding the matter had not been shared with his agency earlier.

Breakout capability

For a state that does not possess nuclear weapons, the capability to produce one or more weapons quickly and with little warning is called a breakout capability.
  • Japan, with its civil nuclear infrastructure and experience, has a stockpile of separated plutonium that could be fabricated into weapons relatively quickly.
  • Iran, according to some observers, may be seeking (or have already achieved) a breakout capability, with its stockpile of low-enriched uranium and its capability to enrich further to weapons grade.

Arguments for and against proliferation

There has been much debate in the academic study of International Security as to the advisability of proliferation. In the late 1950s and early 1960s, Gen. Pierre Marie Gallois of France, an adviser to Charles DeGaulle, argued in books like The Balance of Terror: Strategy for the Nuclear Age (1961) that mere possession of a nuclear arsenal, what the French called the force de frappe, was enough to ensure deterrence, and thus concluded that the spread of nuclear weapons could increase international stability. 

Some very prominent neo-realist scholars, such as Kenneth Waltz, Emeritus Professor of Political Science at UC Berkeley and Adjunct Senior Research Scholar at Columbia University, and John Mearsheimer, R. Wendell Harrison Distinguished Service Professor of Political Science at the University of Chicago, continue to argue along the lines of Gallois in a separate development. Specifically, these scholars advocate some forms of nuclear proliferation, arguing that it will decrease the likelihood of war, especially in troubled regions of the world. Aside from the majority opinion which opposes proliferation in any form, there are two schools of thought on the matter: those, like Mearsheimer, who favor selective proliferation, and those such as Waltz, who advocate a laissez-faire attitude to programs like North Korea's.

Total proliferation

In embryo, Waltz argues that the logic of mutually assured destruction (MAD) should work in all security environments, regardless of historical tensions or recent hostility. He sees the Cold War as the ultimate proof of MAD logic – the only occasion when enmity between two Great Powers did not result in military conflict. This was, he argues, because nuclear weapons promote caution in decision-makers. Neither Washington nor Moscow would risk a nuclear apocalypse to advance territorial or power goals, hence a peaceful stalemate ensued (Waltz and Sagan (2003), p. 24). Waltz believes there to be no reason why this effect would not occur in all circumstances.

Selective proliferation

John Mearsheimer would not support Waltz's optimism in the majority of potential instances; however, he has argued for nuclear proliferation as policy in certain places, such as post–Cold War Europe. In two famous articles, Professor Mearsheimer opines that Europe is bound to return to its pre–Cold War environment of regular conflagration and suspicion at some point in the future. He advocates arming both Germany and Ukraine with nuclear weaponry in order to achieve a balance of power between these states in the east and France/UK in the west. If this does not occur, he is certain that war will eventually break out on the European continent.

Another separate argument against Waltz's open proliferation and in favor of Mearsheimer's selective distribution is the possibility of nuclear terrorism. Some countries included in the aforementioned laissez-faire distribution could predispose the transfer of nuclear materials or a bomb falling into the hands of groups not affiliated with any governments. Such countries would not have the political will or ability to safeguard attempts at devices being transferred to a third party. Not being deterred by self-annihilation, terrorism groups could push forth their own nuclear agendas or be used as shadow fronts to carry out the attack plans by mentioned unstable governments.

Arguments against both positions

There are numerous arguments presented against both selective and total proliferation, generally targeting the very neorealist assumptions (such as the primacy of military security in state agendas, the weakness of international institutions, and the long-run unimportance of economic integration and globalization to state strategy) its proponents tend to make. With respect to Mearsheimer's specific example of Europe, many economists and neoliberals argue that the economic integration of Europe through the development of the European Union has made war in most of the European continent so disastrous economically so as to serve as an effective deterrent. Constructivists take this one step further, frequently arguing that the development of EU political institutions has led or will lead to the development of a nascent European identity, which most states on the European continent wish to partake in to some degree or another, and which makes all states within or aspiring to be within the EU regard war between them as unthinkable. 

As for Waltz, the general opinion is that most states are not in a position to safely guard against nuclear use, that he underestimates the long-standing antipathy in many regions, and that weak states will be unable to prevent – or will actively provide for – the disastrous possibility of nuclear terrorism. Waltz has dealt with all of these objections at some point in his work; though to many, he has not adequately responded (Betts (2000)).

The Learning Channel documentary Doomsday: "On The Brink" illustrated 40 years of U.S. and Soviet nuclear weapons accidents. Even the 1995 Norwegian rocket incident demonstrated a potential scenario in which Russian democratization and military downsizing at the end of the Cold War did not eliminate the danger of accidental nuclear war through command and control errors. After asking: might a future Russian ruler or renegade Russian general be tempted to use nuclear weapons to make foreign policy? The documentary writers revealed a greater danger of Russian security over its nuclear stocks, but especially the ultimate danger of human nature to want the ultimate weapon of mass destruction to exercise political and military power. Future world leaders might not understand how close the Soviets, Russians, and Americans were to doomsday, how easy it all seemed because apocalypse was avoided for a mere 40 years between rivals, politicians not terrorists, who loved their children and did not want to die, against 30,000 years of human prehistory. History and military experts agree that proliferation can be slowed, but never stopped (technology cannot be uninvented).

Proliferation begets proliferation

Proliferation begets proliferation is a concept described by Scott Sagan in his article, "Why Do States Build Nuclear Weapons?". This concept can be described as a strategic chain reaction. If one state produces a nuclear weapon it creates almost a domino effect within the region. States in the region will seek to acquire nuclear weapons to balance or eliminate the security threat. Sagan describes this reaction best in his article when he states, “Every time one state develops nuclear weapons to balance against its main rival, it also creates a nuclear threat to another region, which then has to initiate its own nuclear weapons program to maintain its national security”. Going back through history we can see how this has taken place. When the United States demonstrated that it had nuclear power capabilities after the bombing of Hiroshima and Nagasaki, the Russians started to develop their program in preparation for the Cold War. With the Russian military buildup, France and the United Kingdom perceived this as a security threat and therefore they pursued nuclear weapons (Sagan, pg 71). Even though proliferation causes proliferation, this does not guarantee that other states will successfully develop nuclear weapons because the economic stability of a state plays an important role on whether the state will successfully be able to acquire nuclear weapons. The article written by Dong-Jong Joo and Erik Gartzke discusses how the economy of a country determines whether they will successfully acquire nuclear weapons.

Iran

Former Iranian President Mahmoud Ahmadinejad has been a frequent critic of the concept of "nuclear apartheid" as it has been put into practice by several countries, particularly the United States. In an interview with CNN's Christiane Amanpour, Ahmadinejad said that Iran was "against 'nuclear apartheid,' which means some have the right to possess it, use the fuel, and then sell it to another country for 10 times its value. We're against that. We say clean energy is the right of all countries. But also it is the duty and the responsibility of all countries, including ours, to set up frameworks to stop the proliferation of it." Hours after that interview, he spoke passionately in favor of Iran's right to develop nuclear technology, claiming the nation should have the same liberties.

Iran is a signatory of the Nuclear Non-Proliferation Treaty and claims that any work done in regards to nuclear technology is related only to civilian uses, which is acceptable under the treaty. Iran violated its safeguards obligations under the treaty by performing uranium-enrichment in secret, after which the United Nations Security Council ordered Iran to suspend all uranium-enrichment until July 2015.

India

India has also been discussed in the context of "nuclear apartheid". India has consistently attempted to pass measures that would call for full international disarmament, however they have not succeeded due to protests from those states that already have nuclear weapons. In light of this, India viewed nuclear weapons as a necessary right for all nations as long as certain states were still in possession of nuclear weapons. India stated that nuclear issues were directly related to national security.

Years before India's first underground nuclear test in 1998, the Comprehensive Nuclear-Test-Ban Treaty was passed. Some have argued that coercive language was used in an attempt to persuade India to sign the treaty, which was pushed for heavily by neighboring China. India viewed the treaty as a means for countries that already had nuclear weapons, primarily the five nations of the United Nations Security Council, to keep their weapons while ensuring that no other nations could develop them.

Security guarantees

In their article, "The Correlates of Nuclear Proliferation," Sonali Singh and Christopher R. Way argue that states protected by a security guarantee from a great power, particularly if backed by the "nuclear umbrella" of extended deterrence, have less of an incentive to acquire their own nuclear weapons. States that lack such guarantees are more likely to feel their security threatened and so have greater incentives to bolster or assemble nuclear arsenals. As a result, it is then argued that bipolarity may prevent proliferation where as multipolarity may actually influence proliferation.

Thursday, October 31, 2019

Health equity

From Wikipedia, the free encyclopedia
 
Health gap in England and Wales, 2011 Census
 
Health equity synonymous with health disparity refers to the study and causes of differences in the quality of health and healthcare across different populations. Health equity is different from health equality, as it refers only to the absence of disparities in controllable or remediable aspects of health. It is not possible to work towards complete equality in health, as there are some factors of health that are beyond human influence. Inequity implies some kinds of social injustice. Thus, if one population dies younger than another because of genetic differences, a non-remediable/controllable factor, we tend to say that there is a health inequality. On the other hand, if a population has a lower life expectancy due to lack of access to medications, the situation would be classified as a health inequity. These inequities may include differences in the "presence of disease, health outcomes, or access to health care" between populations with a different race, ethnicity, sexual orientation or socioeconomic status.

Health equity falls into two major categories: horizontal equity, the equal treatment of individuals or groups in the same circumstances; and vertical equity, the principle that individuals who are unequal should be treated differently according to their level of need. Disparities in the quality of health across populations are well-documented globally in both developed and developing nations. The importance of equitable access to healthcare has been cited as crucial to achieving many of the Millennium Development Goals.

Socioeconomic status

Socioeconomic status is both a strong predictor of health, and a key factor underlying health inequities across populations. Poor socioeconomic status has the capacity to profoundly limit the capabilities of an individual or population, manifesting itself through deficiencies in both financial and social capital.[8] It is clear how a lack of financial capital can compromise the capacity to maintain good health. In the UK, prior to the institution of the NHS reforms in the early 2000s, it was shown that income was an important determinant of access to healthcare resources. Because one's job or career is a primary conduit for both financial and social capital, work is an important, yet under represented, factor in health inequities research and prevention efforts. Maintenance of good health through the utilization of proper healthcare resources can be quite costly and therefore unaffordable to certain populations.

In China, for instance, the collapse of the Cooperative Medical System left many of the rural poor uninsured and unable to access the resources necessary to maintain good health. Increases in the cost of medical treatment made healthcare increasingly unaffordable for these populations. This issue was further perpetuated by the rising income inequality in the Chinese population. Poor Chinese were often unable to undergo necessary hospitalization and failed to complete treatment regimens, resulting in poorer health outcomes.

Similarly, in Tanzania, it was demonstrated that wealthier families were far more likely to bring their children to a healthcare provider: a significant step towards stronger healthcare. Some scholars have noted that unequal income distribution itself can be a cause of poorer health for a society as a result of "underinvestment in social goods, such as public education and health care; disruption of social cohesion and the erosion of social capital".

The role of socioeconomic status in health equity extends beyond simple monetary restrictions on an individual's purchasing power. In fact, social capital plays a significant role in the health of individuals and their communities. It has been shown that those who are better connected to the resources provided by the individuals and communities around them (those with more social capital) live longer lives. The segregation of communities on the basis of income occurs in nations worldwide and has a significant impact on quality of health as a result of a decrease in social capital for those trapped in poor neighborhoods. Social interventions, which seek to improve healthcare by enhancing the social resources of a community, are therefore an effective component of campaigns to improve a community's health. A 1998 epidemiological study showed that community healthcare approaches fared far better than individual approaches in the prevention of heart disease mortality.

Unconditional cash transfers for reducing poverty used by some programs in the developing world appear to lead to a reduction in the likelihood of being sick. Such evidence can guide resource allocations to effective interventions.

Education

Education is an important factor in healthcare utilization, though it is closely intertwined with economic status. An individual may not go to a medical professional or seek care if they don’t know the ills of their failure to do so, or the value of proper treatment. In Tajikistan, since the nation gained its independence, the likelihood of giving birth at home has increased rapidly among women with lower educational status. Education also has a significant impact on the quality of prenatal and maternal healthcare. Mothers with primary education consulted a doctor during pregnancy at significantly lower rates (72%) when compared to those with a secondary education (77%), technical training (88%) or a higher education (100%). There is also evidence for a correlation between socioeconomic status and health literacy; one study showed that wealthier Tanzanian families were more likely to recognize disease in their children than those that were coming from lower income backgrounds.

Spatial disparities in health

For some populations, access to healthcare and health resources is physically limited, resulting in health inequities. For instance, an individual might be physically incapable of traveling the distances required to reach healthcare services, or long distances can make seeking regular care unappealing despite the potential benefits.

Global concentrations of healthcare resources, as depicted by the number of physicians per 100,000 individuals, by country.
 
Costa Rica, for example, has demonstrable health spatial inequities with 12–14% of the population living in areas where healthcare is inaccessible. Inequity has decreased in some areas of the nation as a result of the work of healthcare reform programs, however those regions not served by the programs have experienced a slight increase in inequity.

China experienced a serious decrease in spatial health equity following the Chinese economic revolution in the 1980s as a result of the degradation of the Cooperative Medical System (CMS). The CMS provided an infrastructure for the delivery of healthcare to rural locations, as well as a framework to provide funding based upon communal contributions and government subsidies. In its absence, there was a significant decrease in the quantity of healthcare professionals (35.9%), as well as functioning clinics (from 71% to 55% of villages over 14 years) in rural areas, resulting in inequitable healthcare for rural populations. The significant poverty experienced by rural workers (some earning less than 1 USD per day) further limits access to healthcare, and results in malnutrition and poor general hygiene, compounding the loss of healthcare resources. The loss of the CMS has had noticeable impacts on life expectancy, with rural regions such as areas of Western China experiencing significantly lower life expectancies.

Similarly, populations in rural Tajikistan experience spatial health inequities. A study by Jane Falkingham noted that physical access to healthcare was one of the primary factors influencing quality of maternal healthcare. Further, many women in rural areas of the country did not have adequate access to healthcare resources, resulting in poor maternal and neonatal care. These rural women were, for instance, far more likely to give birth in their homes without medical oversight.

Ethnic and racial disparities

Along with the socioeconomic factor of health disparities, race is another key factor. The United States historically had large disparities in health and access to adequate healthcare between races, and current evidence supports the notion that these racially centered disparities continue to exist and are a significant social health issue. The disparities in access to adequate healthcare include differences in the quality of care based on race and overall insurance coverage based on race. A 2002 study in the Journal of the American Medical Association identifies race as a significant determinant in the level of quality of care, with blacks receiving lower quality care than their white counterparts. This is in part because members of ethnic minorities such as African Americans are either earning low incomes, or living below the poverty line. In a 2007 Census Bureau, African American families made an average of $33,916, while their white counterparts made an average of $54,920. Due to a lack of affordable health care, the African American death rate reveals that African Americans have a higher rate of dying from treatable or preventable causes. According to a study conducted in 2005 by the Office of Minority Health—a U.S. Department of Health—African American men were 30% more likely than white men to die from heart disease. Also African American women were 34% more likely to die from breast cancer than their white counterparts.

There are also considerable racial disparities in access to insurance coverage, with ethnic minorities generally having less insurance coverage than non-ethnic minorities. For example, Hispanic Americans tend to have less insurance coverage than white Americans and as a result receive less regular medical care. The level of insurance coverage is directly correlated with access to healthcare including preventative and ambulatory care. A 2010 study on racial and ethnic disparities in health done by the Institute of Medicine has shown that the aforementioned disparities cannot solely be accounted for in terms of certain demographic characteristics like: insurance status, household income, education, age, geographic location and quality of living conditions. Even when the researchers corrected for these factors, the disparities persist. Slavery has contributed to disparate health outcomes for generations of African Americans in the United States.

Ethnic health inequities also appear in nations across the African continent. A survey of the child mortality of major ethnic groups across 11 African nations (Central African Republic, Côte d'Ivoire, Ghana, Kenya, Mali, Namibia, Niger, Rwanda, Senegal, Uganda, and Zambia) was published in 2000 by the WHO. The study described the presence of significant ethnic parities in the child mortality rates among children younger than 5 years old, as well as in education and vaccine use. In South Africa, the legacy of apartheid still manifests itself as a differential access to social services, including healthcare based upon race and social class, and the resultant health inequities. Further, evidence suggests systematic disregard of indigenous populations in a number of countries. The Pygmys of Congo, for instance, are excluded from government health programs, discriminated against during public health campaigns, and receive poorer overall healthcare.

In a survey of five European countries (Sweden, Switzerland, the UK, Italy, and France), a 1995 survey noted that only Sweden provided access to translators for 100% of those who needed it, while the other countries lacked this service potentially compromising healthcare to non-native populations. Given that non-natives composed a considerable section of these nations (6%, 17%, 3%, 1%, and 6% respectively), this could have significant detrimental effects on the health equity of the nation. In France, an older study noted significant differences in access to healthcare between native French populations, and non-French/migrant populations based upon health expenditure; however this was not fully independent of poorer economic and working conditions experienced by these populations.

A 1996 study of race-based health inequity in Australia revealed that Aborigines experienced higher rates of mortality than non-Aborigine populations. Aborigine populations experienced 10 times greater mortality in the 30–40 age range; 2.5 times greater infant mortality rate, and 3 times greater age standardized mortality rate. Rates of diarrheal diseases and tuberculosis are also significantly greater in this population (16 and 15 times greater respectively), which is indicative of the poor healthcare of this ethnic group. At this point in time, the parities in life expectancy at birth between indigenous and non-indigenous peoples were highest in Australia, when compared to the US, Canada and New Zealand. In South America, indigenous populations faced similarly poor health outcomes with maternal and infant mortality rates that were significantly higher (up to 3 to 4 times greater) than the national average. The same pattern of poor indigenous healthcare continues in India, where indigenous groups were shown to experience greater mortality at most stages of life, even when corrected for environmental effects.

LGBT health disparities

Sexuality is a basis of health discrimination and inequity throughout the world. Homosexual, bisexual, transgender, and gender-variant populations around the world experience a range of health problems related to their sexuality and gender identity, some of which are complicated further by limited research. 

In spite of recent advances, LGBT populations in China, India, and Chile continue to face significant discrimination and barriers to care. The World Health Organization (WHO) recognizes that there is inadequate research data about the effects of LGBT discrimination on morbidity and mortality rates in the patient population. In addition, retrospective epidemiological studies on LGBT populations are difficult to conduct as a result of the practice that sexual orientation is not noted on death certificates. WHO has proposed that more research about the LGBT patient population is needed  for improved understanding of its  unique health needs and barriers to accessing care.

Recognizing the need for LGBT healthcare research, the Director of the National Institute on Minority Health and Health Disparities (NIMHD) at the U.S. Department of Health and Human Services designated sexual and gender minorities (SGMs) as a health disparity population for NIH research in October 2016. For the purposes of this designation, the Director defines SGM as "encompass[ing] lesbian, gay, bisexual, and transgender populations, as well as those whose sexual orientation, gender identity and expressions, or reproductive development varies from traditional, societal, cultural, or physiological norms". This designation has prioritized research into the extent, cause, and potential mitigation of health disparities among SGM populations within the larger LGBT community. 

While many aspects of LGBT health disparities are heretofore uninvestigated, at this stage, it is known that one of the main forms of healthcare discrimination  LGBT individuals face is discrimination from healthcare workers or institutions themselves. A systematic literature review of publications in English and Portuguese from 2004–2014 demonstrate significant difficulties in accessing care secondary to discrimination and homophobia from healthcare professionals. This discrimination can take the form of verbal abuse, disrespectful conduct, refusal of care, the withholding of health information,  inadequate treatment, and outright violence. In a study analyzing the quality of healthcare for South African men who have sex with men (MSM), researchers interviewed a cohort of individuals about their health experiences, finding that MSM who identified as homosexual felt their access to healthcare was limited due to an inability to find clinics employing healthcare workers who did not discriminate against their sexuality. They also reportedly faced "homophobic verbal harassment from healthcare workers when presenting for STI treatment". Further, MSM who did not feel comfortable disclosing their sexual activity to healthcare workers failed to identify as homosexuals, which limited the quality of the treatment they received.

Additionally, members of the LGBT community contend with health care disparities due, in part, to lack of provider training and awareness of the population’s healthcare needs. Transgender individuals believe that there is a higher importance of providing gender identity (GI) information more than sexual orientation (SO) to providers to help inform them of better care and safe treatment for these patients. Studies regarding patient-provider communication in the LGBT patient community show that providers themselves report a significant lack of awareness regarding the health issues LGBT-identifying patients face. As a component of this fact, medical schools do not focus much attention on LGBT health issues in their curriculum; the LGBT-related topics that are discussed tend to be limited to HIV/AIDS, sexual orientation, and gender identity.

Among LGBT-identifying individuals, transgender individuals face especially significant barriers to treatment. Many countries still do not have legal recognition of transgender or non-binary gender individuals leading to placement in mis-gendered hospital wards and medical discrimination. Seventeen European states mandate sterilization of individuals who seek recognition of a gender identity that diverges from their birth gender. In addition to many of the same barriers as the rest of the LGBT community, a WHO bulletin points out that globally, transgender individuals often also face a higher disease burden. A 2010 survey of transgender and gender-variant people in the United States revealed that transgender individuals faced a significant level of discrimination. The survey indicated that 19% of individuals experienced a healthcare worker refusing care because of their gender, 28% faced harassment from a healthcare worker, 2% encountered violence, and 50% saw a doctor who was not able or qualified to provide transgender-sensitive care. In Kuwait, there have been reports of transgender individuals being reported to legal authorities by medical professionals, preventing safe access to care. An updated version of the U.S. survey from 2015 showed little change in terms of healthcare experiences for transgender and gender variant individuals. The updated survey revealed that 23% of individuals reported not seeking necessary medical care out of fear of discrimination, and 33% of individuals who had been to a doctor within a year of taking the survey reported negative encounters with medical professionals related to their transgender status.

The stigmatization represented particularly in the transgender population  creates a health disparity for LGBT individuals with regard to mental health. The LGBT community is at increased risk for psychosocial distress, mental health complications, suicidality, homelessness, and substance abuse, often complicated by access-based under-utilization or fear of health services. Transgender and gender-variant individuals have been found to experience higher rates of mental health disparity than LGB individuals. According to the 2015 U.S. Transgender Survey, for example, 39% of respondents reported serious psychological distress, compared to 5% of the general population.

These mental health facts are informed by a history of anti-LGBT bias in health care. The Diagnostic and Statistical Manual of Mental Disorders (DSM) listed homosexuality as a disorder until 1973; transgender status was listed as a disorder until 2012. This was amended in 2013 with the DSM-5 when "gender identity disorder" was replaced with "gender dysphoria", reflecting that simply identifying as transgender is not itself pathological and that the diagnosis is instead for the distress a transgender person may experience as a result of the discordance between assigned gender and gender identity.

LGBT health issues have received disproportionately low levels of medical research, leading to difficulties in assessing appropriate strategies for LGBT treatment. For instance, a review of medical literature regarding LGBT patients revealed that there are significant gaps in the medical understanding of cervical cancer in lesbian and bisexual individuals it is unclear whether its prevalence in this community is a result of probability or some other preventable cause. For example, LGBT people report poorer cancer care experiences. It is incorrectly assumed that LGBT women have a lower incidence of cervical cancer than their heterosexual counterparts, resulting in lower rates of screening.  Such findings illustrate the need for continued research focused on the circumstances and needs of LGBT individuals and the inclusion in policy frameworks of sexual orientation and gender identity as social determinants of health.

A June 2017 review sponsored by the European commission as part of a larger project to identify and diminish health inequities, found that LGB are at higher risk of some cancers and that LGBTI were at higher risk of mental illness, and that these risks were not adequately addressed. The causes of health inequities were, according to the review, "i) cultural and social norms that preference and prioritise heterosexuality; ii) minority stress associated with sexual orientation, gender identity and sex characteristics; iii) victimisation; iv) discrimination (individual and institutional), and; v) stigma."

Sex and gender in healthcare equity

Sex and gender in medicine

Both gender and sex are significant factors that influence health. Sex is characterized by female and male biological differences in regards to gene expression, hormonal concentration, and anatomical characteristics. Gender is an expression of behavior and lifestyle choices. Both sex and gender inform each other, and it is important to note that differences between the two genders influence disease manifestation and associated healthcare approaches. Understanding how the interaction of sex and gender contributes to disparity in the context of health allows providers to ensure quality outcomes for patients. This interaction is complicated by the difficulty of distinguishing between sex and gender given their intertwined nature; sex modifies gender, and gender can modify sex, thereby impacting health.  Sex and gender can both be considered sources of health disparity; both contribute to men and women’s susceptibility to various health conditions, including cardiovascular disease and autoimmune disorders.

Health disparities in the male population

As sex and gender are inextricably linked in day-to-day life, their union is apparent in medicine. Gender and sex are both components of health disparity in the male population. In non-Western regions, males tend to have a health advantage over women due to gender discrimination, evidenced by infanticide, early marriage, and domestic abuse for females. In most regions of the world, the mortality rate is higher for adult men than for adult women; for example, adult men suffer from fatal illnesses with more frequency than females. The leading causes of the higher male death rate are accidents, injuries, violence, and cardiovascular diseases. In a number of countries, males also face a heightened risk of mortality as a result of behavior and greater propensity for violence.

Physicians tend to offer invasive procedures to male patients more than female patients. Furthermore, men are more likely to smoke than women and experience smoking-related health complications later in life as a result; this trend is also observed in regard to other substances, such as marijuana, in Jamaica, where the rate of use is 2–3 times more for men than women. Lastly, men are more likely to have severe chronic conditions and a lower life expectancy than women in the United States.

Health disparities in the female population

Gender and sex are also components of health disparity in the female population. The 2012 World Development Report (WDR) noted that women in developing nations experience greater mortality rates than men in developing nations. Additionally, women in developing countries have a much higher risk of maternal death than those in developed countries. The highest risk of dying during childbirth is 1 in 6 in Afghanistan and Sierra Leone, compared to nearly 1 in 30,000 in Sweden—a disparity that is much greater than that for neonatal or child mortality.

While women in the United States tend to live longer than men, they generally are of lower socioeconomic status (SES) and therefore have more barriers to accessing healthcare. Being of lower SES also tends to increase societal pressures, which can lead to higher rates of depression and chronic stress and, in turn, negatively impact health. Women are also more likely than men to suffer from sexual or intimate-partner violence both in the United States and worldwide. In Europe, women who grew up in poverty are more likely to have lower muscle strength and higher disability in old age.

Women have better access to healthcare in the United States than they do in many other places in the world. In one population study conducted in Harlem, New York, 86% of women reported having privatized or publicly assisted health insurance, while only 74% of men reported having any health insurance. This trend is representative of the general population of the United States.

In addition, women's pain tends to be treated less seriously and initially ignored by clinicians when compared to their treatment of men's pain complaints. Historically, women have not been included in the design or practice of clinical trials, which has slowed the understanding of women's reactions to medications and created a research gap. This has led to post-approval adverse events among women, resulting in several drugs being pulled from the market. However, the clinical research industry is aware of the problem, and has made progress in correcting it.

Cultural factors

Health disparities are also due in part to cultural factors that involve practices based not only on sex, but also gender status. For example, in China, health disparities have distinguished medical treatment for men and women due to the cultural phenomenon of preference for male children. Recently, gender-based disparities have decreased as females have begun to receive higher-quality care. Additionally, a girl’s chances of survival are impacted by the presence of a male sibling; while girls do have the same chance of survival as boys if they are the oldest girl, they have a higher probability of being aborted or dying young if they have an older sister.

In India, gender-based health inequities are apparent in early childhood. Many families provide better nutrition for boys in the interest of maximizing future productivity given that boys are generally seen as breadwinners. In addition, boys receive better care than girls and are hospitalized at a greater rate. The magnitude of these disparities increases with the severity of poverty in a given population.

Additionally, the cultural practice of female genital mutilation (FGM) is known to impact women's health, though is difficult to know the worldwide extent of this practice. While generally thought of as a Sub-Saharan African practice, it may have roots in the Middle East as well. The estimated 3 million girls who are subjected to FGM each year potentially suffer both immediate and lifelong negative effects. Immediately following FGM, girls commonly experience excessive bleeding and urine retention. Long-term consequences include urinary tract infections, bacterial vaginosis, pain during intercourse, and difficulties in childbirth that include prolonged labor, vaginal tears, and excessive bleeding. Women who have undergone FGM also have higher rates of post-traumatic stress disorder (PTSD) and herpes simplex virus 2 (HSV2) than women who have not.

Health inequality and environmental influence

Minority populations have increased exposure to environmental hazards that include lack of neighborhood resources, structural and community factors as well as residential segregation that result in a cycle of disease and stress. The environment that surrounds us can influence individual behaviors and lead to poor health choices and therefore outcomes. Minority neighborhoods have been continuously noted to have more fast food chains and fewer grocery stores than predominantly white neighborhoods. These food deserts affect a family’s ability to have easy access to nutritious food for their children. This lack of nutritious food extends beyond the household into the schools that have a variety of vending machines and deliver over processed foods. These environmental condition have social ramifications and in the first time in US history is it projected that the current generation will live shorter lives than their predecessors will.

In addition, minority neighborhoods have various health hazards that result from living close to highways and toxic waste factories or general dilapidated structures and streets. These environmental conditions create varying degrees of health risk from noise pollution, to carcinogenic toxic exposures from asbestos and radon that result in increase chronic disease, morbidity, and mortality. The quality of residential environment such as damaged housing has been shown to increase the risk of adverse birth outcomes, which is reflective of a communities health. Housing conditions can create varying degrees of health risk that lead to complications of birth and long-term consequences in the aging population. In addition, occupational hazards can add to the detrimental effects of poor housing conditions. It has been reported that a greater number of minorities work in jobs that have higher rates of exposure to toxic chemical, dust and fumes.

Racial segregation is another environmental factor that occurs through the discriminatory action of those organizations and working individuals within the real estate industry, whether in the housing markets or rentals. Even though residential segregation is noted in all minority groups, blacks tend to be segregated regardless of income level when compared to Latinos and Asians. Thus, segregation results in minorities clustering in poor neighborhoods that have limited employment, medical care, and educational resources, which is associated with high rates of criminal behavior. In addition, segregation affects the health of individual residents because the environment is not conducive to physical exercise due to unsafe neighborhoods that lack recreational facilities and have nonexistent park space. Racial and ethnic discrimination adds an additional element to the environment that individuals have to interact with daily. Individuals that reported discrimination have been shown to have an increase risk of hypertension in addition to other physiological stress related affects. The high magnitude of environmental, structural, socioeconomic stressors leads to further compromise on the psychological and physical being, which leads to poor health and disease.

Individuals living in rural areas, especially poor rural areas, have access to fewer health care resources. Although 20 percent of the U.S. population lives in rural areas, only 9 percent of physicians practice in rural settings. Individuals in rural areas typically must travel longer distances for care, experience long waiting times at clinics, or are unable to obtain the necessary health care they need in a timely manner. Rural areas characterized by a largely Hispanic population average 5.3 physicians per 10,000 residents compared with 8.7 physicians per 10,000 residents in nonrural areas. Financial barriers to access, including lack of health insurance, are also common among the urban poor.

Disparities in access to health care

Reasons for disparities in access to health care are many, but can include the following:
  • Lack of universal health care or health insurance coverage. Without health insurance, patients are more likely to postpone medical care, go without needed medical care, go without prescription medicines, and be denied access to care. Minority groups in the United States lack insurance coverage at higher rates than whites. This problem does not exist in countries with fully funded public health systems, such as the examplar of the NHS.
  • Lack of a regular source of care. Without access to a regular source of care, patients have greater difficulty obtaining care, fewer doctor visits, and more difficulty obtaining prescription drugs. Compared to whites, minority groups in the United States are less likely to have a doctor they go to on a regular basis and are more likely to use emergency rooms and clinics as their regular source of care. In the United Kingdom, which is much more racially harmonious, this issue arises for a different reason; since 2004, NHS GPs have not been responsible for care out of normal GP surgery opening hours, leading to significantly higher attendances in A+E
  • Lack of financial resources. Although the lack of financial resources is a barrier to health care access for many Americans, the impact on access appears to be greater for minority populations.
  • Legal barriers. Access to medical care by low-income immigrant minorities can be hindered by legal barriers to public insurance programs. For example, in the United States federal law bars states from providing Medicaid coverage to immigrants who have been in the country fewer than five years. Another example could be when a non-English speaking person attends a clinic where the receptionist does not speak the person's language. This is mostly seen in Hispanic people who do not speak English.
  • Structural barriers. These barriers include poor transportation, an inability to schedule appointments quickly or during convenient hours, and excessive time spent in the waiting room, all of which affect a person's ability and willingness to obtain needed care.
  • The health care financing system. The Institute of Medicine in the United States says fragmentation of the U.S. health care delivery and financing system is a barrier to accessing care. Racial and ethnic minorities are more likely to be enrolled in health insurance plans which place limits on covered services and offer a limited number of health care providers.
  • Scarcity of providers. In inner cities, rural areas, and communities with high concentrations of minority populations, access to medical care can be limited due to the scarcity of primary care practitioners, specialists, and diagnostic facilities. In the UK, Monitor (a quango) has a legal obligation to ensure that sufficient provision exists in all parts of the nation.
  • Linguistic barriers. Language differences restrict access to medical care for minorities in the United States who are not English-proficient.
  • Health literacy. This is where patients have problems obtaining, processing, and understanding basic health information. For example, patients with a poor understanding of good health may not know when it is necessary to seek care for certain symptoms. While problems with health literacy are not limited to minority groups, the problem can be more pronounced in these groups than in whites due to socioeconomic and educational factors. A study conducted in Mdantsane, South Africa depicts the correlation of maternal education and the antenatal visits for pregnancy. As patients have a greater education, they tend to use maternal health care services more than those with a lesser maternal education background.
  • Lack of diversity in the health care workforce. A major reason for disparities in access to care are the cultural differences between predominantly white health care providers and minority patients. Only 4% of physicians in the United States are African American, and Hispanics represent just 5%, even though these percentages are much less than their groups' proportion of the United States population.
  • Age. Age can also be a factor in health disparities for a number of reasons. As many older Americans exist on fixed incomes which may make paying for health care expenses difficult. Additionally, they may face other barriers such as impaired mobility or lack of transportation which make accessing health care services challenging for them physically. Also, they may not have the opportunity to access health information via the internet as less than 15% of Americans over the age of 65 have access to the internet. This could put older individuals at a disadvantage in terms of accessing valuable information about their health and how to protect it. On the other hand, older individuals in the US (65 or above) are provided with medical care via Medicare.

Disparities in quality of health care

Health disparities in the quality of care exist and are based on language and ethnicity/race which includes:

Problems with patient-provider communication

Communication is critical for the delivery of appropriate and effective treatment and care, regardless of a patient’s race, and miscommunication can lead to incorrect diagnosis, improper use of medications, and failure to receive follow-up care. The patient provider relationship is dependent on the ability of both individuals to effectively communicate. Language and culture both play a significant role in communication during a medical visit. Among the patient population, minorities face greater difficulty in communicating with their physicians. Patients when surveyed responded that 19% of the time they have problems communicating with their providers which included understanding doctor, feeling doctor listened, and had questions but did not ask. In contrast, the Hispanic population had the largest problem communicating with their provider, 33% of the time. Communication has been linked to health outcomes, as communication improves so does patient satisfaction which leads to improved compliance and then to improved health outcomes. Quality of care is impacted as a result of an inability to communicate with health care providers. Language plays a pivotal role in communication and efforts need to be taken to ensure excellent communication between patient and provider. Among limited English proficient patients in the United States, the linguistic barrier is even greater. Less than half of non-English speakers who say they need an interpreter during clinical visits report having one. The absence of interpreters during a clinical visit adds to the communication barrier. Furthermore, inability of providers to communicate with limited English proficient patients leads to more diagnostic procedures, more invasive procedures, and over prescribing of medications. Poor communication contributes to poor medical compliance and health outcomes. Many health-related settings provide interpreter services for their limited English proficient patients. This has been helpful when providers do not speak the same language as the patient. However, there is mounting evidence that patients need to communicate with a language concordant physician (not simply an interpreter) to receive the best medical care, bond with the physician, and be satisfied with the care experience. Having patient-physician language discordant pairs (i.e. Spanish-speaking patient with an English-speaking physician) may also lead to greater medical expenditures and thus higher costs to the organization. Additional communication problems result from a decrease or lack of cultural competence by providers. It is important for providers to be cognizant of patients’ health beliefs and practices without being judgmental or reacting. Understanding a patients’ view of health and disease is important for diagnosis and treatment. So providers need to assess patients’ health beliefs and practices to improve quality of care. Patient health decisions can be influenced by religious beliefs, mistrust of Western medicine, and familial and hierarchical roles, all of which a white provider may not be familiar with. Other type of communication problems are seen in LGBT health care with the spoken heterosexist (conscious or unconscious) attitude on LGBT patients, lack of understanding on issues like having no sex with men (lesbians, gynecologic examinations) and other issues.

Provider discrimination

Provider discrimination occurs when health care providers either unconsciously or consciously treat certain racial and ethnic patients differently from other patients. This may be due to stereotypes that providers may have towards ethnic/racial groups. Doctors are more likely to ascribe negative racial stereotypes to their minority patients. This may occur regardless of consideration for education, income, and personality characteristics. Two types of stereotypes may be involved, automatic stereotypes or goal modified stereotypes. Automated stereotyping is when stereotypes are automatically activated and influence judgments/behaviors outside of consciousness. Goal modified stereotype is a more conscious process, done when specific needs of clinician arise (time constraints, filling in gaps in information needed) to make a complex decisions. Physicians are unaware of their implicit biases. Some research suggests that ethnic minorities are less likely than whites to receive a kidney transplant once on dialysis or to receive pain medication for bone fractures. Critics question this research and say further studies are needed to determine how doctors and patients make their treatment decisions. Others argue that certain diseases cluster by ethnicity and that clinical decision making does not always reflect these differences.

Lack of preventive care

According to the 2009 National Healthcare Disparities Report, uninsured Americans are less likely to receive preventive services in health care. For example, minorities are not regularly screened for colon cancer and the death rate for colon cancer has increased among African Americans and Hispanic populations. Furthermore, limited English proficient patients are also less likely to receive preventive health services such as mammograms. Studies have shown that use of professional interpreters have significantly reduced disparities in the rates of fecal occult testing, flu immunizations and pap smears. In the UK, Public Health England, a universal service free at the point of use, which forms part of the NHS, offers regular screening to any member of the population considered to be in an at-risk group (such as individuals over 45) for major disease (such as colon cancer, or diabetic-retinopathy).

Plans for achieving health equity

There are a multitude of strategies for achieving health equity and reducing disparities outlined in scholarly texts, some examples include:
  • Advocacy. Advocacy for health equity has been identified as a key means of promoting favourable policy change. EuroHealthNet carried out a systematic review of the academic and grey literature. It found, amongst other things, that certain kinds of evidence may be more persuasive in advocacy efforts, that practices associated with knowledge transfer and translation can increase the uptake of knowledge, that there are many different potential advocates and targets of advocacy and that advocacy efforts need to be tailored according to context and target. As a result of its work, it produced an online advocacy for health equity toolkit.
  • Provider based incentives to improve healthcare for ethnic populations. One source of health inequity stems from unequal treatment of non-white patients in comparison with white patients. Creating provider based incentives to create greater parity between treatment of white and non-white patients is one proposed solution to eliminate provider bias. These incentives typically are monetary because of its effectiveness in influencing physician behavior.
  • Using Evidence Based Medicine (EBM). Evidence Based Medicine (EBM) shows promise in reducing healthcare provider bias in turn promoting health equity. In theory EBM can reduce disparities however other research suggests that it might exacerbate them instead. Some cited shortcomings include EBM’s injection of clinical inflexibility in decision making and its origins as a purely cost driven measure.
  • Increasing awareness. The most cited measure to improving health equity relates to increasing public awareness. A lack of public awareness is a key reason why there has not been significant gains in reducing health disparities in ethnic and minority populations. Increased public awareness would lead to increased congressional awareness, greater availability of disparity data, and further research into the issue of health disparities.
  • The Gradient Evaluation Framework. The evidence base defining which policies and interventions are most effective in reducing health inequalities is extremely weak. It is important therefore that policies and interventions which seek to influence health inequity be more adequately evaluated. Gradient Evaluation Framework (GEF) is an action-oriented policy tool that can be applied to assess whether policies will contribute to greater health equity amongst children and their families.
  • The AIM framework. In a pilot study, researchers examined the role of AIM—ability, incentives, and management feedback—in reducing care disparity in pressure-ulcer detection between African American and Caucasian residents. The results showed that while the program was implemented, the provision of (1) training to enhance ability, (2) monetary incentives to enhance motivation, and (3) management feedback to enhance accountability led to successful reduction in pressure ulcers. Specifically, the detection gap between the two groups decreased. The researchers suggested additional replications with longer duration to assess the effectiveness of the AIM framework.
  • Monitoring actions on the social determinants of health. In 2017, citing the need for accountability for the pledges made by countries in the Rio Political Declaration on Social Determinants of Health, the World Health Organization and United Nations Children's Fund called for the monitoring of intersectoral interventions on the social determinants of health that improve health equity.

Health inequalities

Health inequality is the term used in a number of countries to refer to those instances whereby the health of two demographic groups (not necessarily ethnic or racial groups) differs despite comparative access to health care services. Such examples include higher rates of morbidity and mortality for those in lower occupational classes than those in higher occupational classes, and the increased likelihood of those from ethnic minorities being diagnosed with a mental health disorder. In Canada, the issue was brought to public attention by the LaLonde report

In UK, the Black Report was produced in 1980 to highlight inequalities. On 11 February 2010, Sir Michael Marmot, an epidemiologist at University College London, published the Fair Society, Healthy Lives report on the relationship between health and poverty. Marmot described his findings as illustrating a "social gradient in health": the life expectancy for the poorest is seven years shorter than for the most wealthy, and the poor are more likely to have a disability. In its report on this study, The Economist argued that the material causes of this contextual health inequality include unhealthful lifestyles - smoking remains more common, and obesity is increasing fastest, amongst the poor in Britain.

In June 2018, the European Commission launched the Joint Action Health Equity in Europe. Forty-nine participants from 25 European Union Member States will work together to address health inequalities and the underlying social determinants of health across Europe. Under the coordination of the Italian Institute of Public Health, the Joint Action aims to achieve greater equity in health in Europe across all social groups while reducing the inter-country heterogeneity in tackling health inequalities.

Poor health and economic inequality

Poor health outcomes appear to be an effect of economic inequality across a population. Nations and regions with greater economic inequality show poorer outcomes in life expectancy, mental health, drug abuse, obesity, educational performance, teenage birthrates, and ill health due to violence. On an international level, there is a positive correlation between developed countries with high economic equality and longevity. This is unrelated to average income per capita in wealthy nations. Economic gain only impacts life expectancy to a great degree in countries in which the mean per capita annual income is less than approximately $25,000. The United States shows exceptionally low health outcomes for a developed country, despite having the highest national healthcare expenditure in the world. The US ranks 31st in life expectancy. Americans have a lower life expectancy than their European counterparts, even when factors such as race, income, diet, smoking, and education are controlled for.

Relative inequality negatively affects health on an international, national, and institutional levels. The patterns seen internationally hold true between more and less economically equal states in the United States. The patterns seen internationally hold true between more and less economically equal states in the United States, that is, more equal states show more desirable health outcomes. Importantly, inequality can have a negative health impact on members of lower echelons of institutions. The Whitehall I and II studies looked at the rates of cardiovascular disease and other health risks in British civil servants and found that, even when lifestyle factors were controlled for, members of lower status in the institution showed increased mortality and morbidity on a sliding downward scale from their higher status counterparts. The negative aspects of inequality are spread across the population. For example, when comparing the United States (a more unequal nation) to England (a less unequal nation), the US shows higher rates of diabetes, hypertension, cancer, lung disease, and heart disease across all income levels. This is also true of the difference between mortality across all occupational classes in highly equal Sweden as compared to less-equal England.

Inequality (mathematics)

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