Security and Public Health

Simon Rushton

• Publisher: Polity
• Year: 2019
• ISBN:
  9781509515929
• Edition: 1
• Topic: Politica e relazioni internazionali
• Subtopic: Globalizzazione

For most Western governments, defending against the threat of infectious disease is now an accepted security priority. Deciding what resources and policies to put in place to protect populations from pandemics, however, involves difficult political choices. How can we get these decisions right? And what are we prepared to sacrifice to achieve better health security?

In this book, Simon Rushton explores the politics of pandemics in the contemporary world. Looking back over three decades of public health, he traces national and international efforts to tackle infectious disease, focusing in-depth on three core areas in which securitization has been particularly successful: rapidly spreading pandemic diseases, HIV/AIDS and man-made pathogenic threats, such as biological weapons. Three central problems raised by common responses to disease as a security threat are then examined: the impact upon individuals and civil liberties; the tendency to treat the symptoms and not the underlying causes of disease outbreaks; and the limited range of diseases deemed worthy of global attention and action. Arguing against a tendency to treat global health security as a technical challenge, the book stresses the need for a vibrant, and even confrontational, political engagement around the implications of securitizing public health.

1
Pandemics and Global Health Security

In early 2009, something unusual was happening in Mexico. A cluster of influenza infections around Veracruz was eventually recognized as something more significant: early cases of a new strain of the influenza virus with pandemic potential. Information in the early stages was scarce. It wasn't clear where the new strain had come from, how easily the virus was transmitting between people, or what the fatality rate was. Initially the death toll in Mexico seemed extremely high, prompting concerns that the next ‘big one’, comparable to the Spanish flu epidemic that followed the First World War, had arrived.

The new strain of the virus – officially labelled H1N1, but more commonly known as ‘swine flu’ – quickly spread around the world. The fact that it gradually became clear that the fatality rate was not as high as had originally been assumed eventually calmed fears somewhat. But not before most states had implemented their pandemic preparedness plans, and the WHO had (for the first time ever) declared a ‘public health emergency of international concern’.

In the previous chapter, I argued that the idea that infectious diseases represent a threat to national and international security is now well established – and indeed has long historical precedents, even if the language of national and international security was used less frequently in the past. I argued that rather than continuing to debate whether we should or should not securitize disease, we need to pay more attention than we have done so far to three important questions: how much security do we feel we need from disease threats? What are we prepared to sacrifice to achieve that level of security? And, what are the conditions under which security logics prevail in guiding responses to perceived disease threats?

This chapter begins the process of analysing these questions. I focus on pandemics of rapidly-spreading and deadly diseases – perhaps the most obvious, and certainly the most emblematic, of all health security threats. I describe the way in which pathogens, most notably Emerging and Re-emerging Infectious Diseases (ERIDs) and pandemic strains of influenza (pandemic flu), came to be widely accepted as national and international security concerns, particularly amongst governments in the Global North. I discuss the international mechanisms that are supposed to mitigate the effects of such crises and how they seek to balance states’ security and trade interests. However, as I discuss in the second part of the chapter, national and international security can be in tension with one another – especially in the emergency conditions of a major health emergency. Examining border closures as a common policy response, I show that in many cases we have seen governments facing a perceived crisis prioritizing their own national security and ignoring their obligations within the international cooperative arrangements that are supposed to provide for what has come to be known as ‘global health security’. Are these tensions inevitable during an emergency? If so, why don't all governments act in this way? And is it possible, politically, to move towards achieving security from pandemics in a way that incorporates a greater degree of international solidarity?

Epidemics and Pandemics

The terms ‘epidemic’ and ‘pandemic’ are often used interchangeably in the statements of policymakers, and also in the wider public discourse. To some extent the difference is academic given that both can be understood as posing security threats to populations and the state. Yet the distinction between the two terms does guide our attention towards important issues of scale and territory. The sixth edition of A Dictionary of Epidemiology (Porta 2014) defines an epidemic as ‘The occurrence in a community or region of cases of an illness, specific health-related behavior, or other health-related events clearly in excess of normal expectancy.’ The crucial difference here is between that which would normally be expected (in epidemiological terms, diseases that are ‘endemic’) in a particular population, and something unusual, new or unexpected. A pandemic, meanwhile, is defined as ‘An epidemic occurring over a very wide area, crossing international boundaries, and usually affecting a large number of people.’ The key differences between an epidemic and a pandemic, therefore, are of scale (the number of people infected) and territory (the geographical area affected).

In technical public health terms, the words epidemic and pandemic tell us only about epidemiology; about how far and to whom a disease has spread. They tell us nothing about the severity of the disease. The Dictionary of Epidemiology's definition of pandemic, indeed, goes on to warn the reader that ‘Only some pandemics cause severe disease in some individuals or at a population level’ (Porta 2014).

Such technical definitions, however, only get us so far. Beyond the world of professional epidemiologists, ‘epidemic’ and ‘pandemic’ are powerful words that can have significant effects. As Sander L. Gilman wrote in The Lancet, reflecting on the H1N1 ‘swine flu’ pandemic of 2009:

‘epidemic’ maintains a powerful metaphorical connection to universal, lethal contagion from its earliest to its most recent use. Epidemic and pandemic have a strong metaphorical use in terms of the unfettered spread of deadly and uncontrolled diseases and have always had social and emotional consequences. (Gilman 2010: 1866)

To this, we might add that the use of these terms can also have significant political and economic effects. Policy-makers are, of course, acutely aware of this. In dealing with swine flu, even the WHO, often seen as a highly technical agency, showed full cognizance of the political and economic consequences of labelling the outbreak a pandemic. In the early stages, indeed, the organization resisted officially declaring a pandemic. According to the WHO's official updates, by 21 May 2009, laboratory-confirmed cases of H1N1 influenza had been reported by forty-one countries. With the exception of Africa, which at that stage had not declared any laboratory-confirmed cases (almost certainly due to a lack of laboratory testing rather than the absence of the virus), every WHO region had seen cases. The H1N1 virus was certainly global in its spread, of that there was no doubt. A large number of people had been affected. The dictionary definition of ‘pandemic’ seemed to have been met. Yet Margaret Chan, the WHO's Director-General, decided on that day not to declare a pandemic, apparently as a result of concerns about the panic that may have resulted (Gilman 2010). A month later, on 11 June 2009, and under significant pressure as a result of public concern, the WHO did declare a pandemic on the grounds that ‘the scientific criteria for an influenza pandemic have been met’ (Chan 2009).

Once it had declared a pandemic, the WHO came in for severe criticism. Questions were raised around the impartiality of its decision-making and whether or not severity ought to be part of the criteria for a pandemic declaration, given that this flu strain was now being recognized as relatively mild (Doshi 2011). The Parliamentary Assembly of the Council of Europe (2010) heavily criticized the organization for causing ‘unjustified scares and fears about health risks’, and raised the possibility that the pharmaceutical industry may have had an influence on ‘some of the major decisions relating to the pandemic.’ The WHO responded robustly, defending the impartiality of its expert advice and stating that ‘WHO has not required a set level of severity as part of its criteria for declaring a pandemic. Experience shows that all pandemics cause excess deaths, that severity can change over time, and that severity can vary according to location and population’ (WHO 2010). Nevertheless, whilst the WHO may have been technically correct in pointing out (as per the definitions above) that a pandemic is defined by spread not severity, it did a poor job of communicating this nuance to the general public and the media, leading to confusion and fear (Fineberg 2014: 1339).

This spat, which rumbled on for several months, revealed three important things for the discussion in this chapter. First, it highlighted the fact that the language that is used about outbreaks matters, and that the language used around infectious disease quickly becomes highly political. The term ‘pandemic’ is one example of this; ‘health security’ is another. Second, it showed that the WHO's pronouncements can have real implications for national and international security practices. The pandemic declaration triggered a range of actions at global, regional and national levels in line with the (then) guidance that ‘For Phases 5–6 (pandemic), actions shift from preparedness to response at a global level. The goal of recommended actions during these phases is to reduce the impact of the pandemic on society’ (WHO 2009: 41). Third, and finally, the controversy had implications for the way the WHO dealt with subsequent outbreaks. Having faced criticism for supposedly fear-mongering over swine flu, the organization later came under attack for being too slow to declare Ebola in West Africa an emergency. Some claimed the two were directly linked, arguing that ‘the WHO may have hesitated to flag up the Ebola outbreak after it was accused of overhyping the 2009 H1N1 swine flu epidemic’ (Flynn and Nebehay 2014).

Looking back on the 2009 H1N1 pandemic with the benefit of hindsight, it is easy to come to the conclusion that it was indeed the subject of excessive hype. This was not the next ‘big one’. (At the time of writing this book, we are still awaiting the next ‘big one’ that, virologists warn us, will eventually emerge; Harmon 2011.) The fact that the terrifying mortality forecasts of some experts did not come to pass seems to legitimate a view that swine flu was never really a threat. Such feelings are a major contributor to what Price-Smith and Porreca (2016) have called the ‘fear/apathy cycle’. But to dismiss the significance of the pandemic in this way misses three important points: that knowledge of the virus's virulence was developing as it spread across the world; that many people did die as a result of contracting the disease (as they do each year of seasonal flu); and that even if the consequences of the pandemic were less devastating than many feared, it nevertheless played into – and reinvigorated – longstanding narratives about the security threat posed by infectious diseases in a globalized world.

Global and National Health Security

In April 2001, the World Health Organization's Secretariat delivered a report to the World Health Assembly (the forum in which the Organization's 194 member states meet) entitled ‘Global health security – epidemic alert and response’ (WHO 2001). In that report, the authors neatly encapsulated the central set of claims at the heart of what has since become the well-established concept of ‘global health security’. They said that

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