Global Public Health Vigilance

Lorna Weir,Eric Mykhalovskiy

• Publisher: Routledge
• Year: 2010
• ISBN:
  9781135159153
• Edition: 1
• Topic: Computer Science
• Subtopic: Social Aspects in Computer Science
• Index: Computer Science

Global Public Health Vigilance is the first sociological book to investigate recent changes in how global public health authorities imagine and respond to international threats to human health.

This book explores a remarkable period of conceptual innovation during which infectious disease, historically the focus of international disease control, was displaced by "international public health emergencies, " a concept that brought new responsibilities to public health authorities, helping to shape a new project of global public health security.

Drawing on research conducted at the World Health Organization, this book analyzes the formation of a new social apparatus, global public health vigilance, for detecting, responding to and containing international public health emergencies. Between 1995 and 2005 a new form of global health surveillance was invented, international communicable disease control was securitized, and international health law was fundamentally revised.

This timely volume raises critical questions about the institutional effects of the concept of emerging infectious diseases, the role of the news media in global health surveillance, the impact of changes in international health law on public health reasoning and practice, and the reconstitution of the World Health Organization as a power beyond national sovereignty and global governance. It initiates a new research agenda for social science research on public health.

1
Knowing Global Public Health

Infectious diseases have again become culturally fascinating to the peoples of the global North. Avian flu and swine flu are endlessly newsworthy topics. Novels and nonfiction books about epidemics become best sellers. Films about fictionalized contagious disease outbreaks attract audiences who have acquired a taste for being scared by really nasty bugs.

The present book is a study in another aspect of this interest in infectious diseases: public health expertise, specifically changes that have occurred since the late 1990s in how international public health authorities come to know about internationally significant infectious disease outbreaks and other emergencies. Whereas prior to the mid-1990s the World Health Organization (WHO) was charged with preventing the international transmission of a small number of infectious diseases,¹ today global public health security targets the much more expansive target of international public health emergencies. We seek to understand this very recent historical break in global public health by analyzing the transformation in international communicable disease control in terms of three processes: (1) the impact of a new disease concept called ‘emerging infectious diseases’ (EID), (2) the invention of a monitoring/surveillance technique called ‘online early warning outbreak detection,’ and (3) the formation of a politico-juridical regime dealing with international public health emergencies.

Our interest in contemporary global public health knowledge of infectious disease outbreaks and other health emergencies was sparked by the 2003 SARS outbreak in Toronto, Canada. We each initially knew SARS through TV, radio, talking with friends, and contacts with public health officials. Weir, who lives in Toronto, also experienced the reactions of people local to the outbreak by speaking with family members of those who were ill, noticing hospital measures for infectious disease control, and seeing fewer people in restaurants. We observed that our experiences of SARS in Toronto and in Halifax, Canada (where Mykhalovskiy lived at the time) were mediated through local and global news reports that presented us with images of Canadian public health officials in dialogue with WHO, the latter coordinating global efforts to control SARS. In Canada, the SARS outbreak precipitated debate about the political effects of travel advisories and the evidentiary basis upon which are based public health judgments about issuing and lifting them (Kraus 2003). It also spurred widespread discussion about the processes for identifying and responding to infectious disease outbreaks that, like SARS, can quickly traverse the globe.

This book represents our collaborative effort to understand how infectious disease outbreaks and other events currently come into knowledge within global public health. It is the result of an intellectual and research journey that began with our conversations in Toronto about SARS and continued into our meeting and interviewing officials at WHO in Geneva together with research at the WHO Library and Archives. Along the way we interviewed public health officials at the Global Public Health Intelligence Network (GPHIN) based in Ottawa, Canada, and wrestled with the complex technical innovations that they and others had introduced into contemporary international infectious disease monitoring. We read international and Canadian government reports about the SARS outbreak that emphasized the need to improve how outbreaks and emergencies are identified and acted on both domestically and globally. We attended national and international conferences on infectious diseases in Australia, Canada, Europe, and the USA. We learned about new concepts such as ‘emerging infectious diseases’ and ‘public health emergencies of international concern,’ read about global health governance, and waded through the impressive historical and contemporary work on international infectious disease control. We also struggled with the available frameworks for understanding current public health governance arrangements as we sought to make sense of our research object.

Throughout the process, we were struck by the paucity of sociological attention to contemporary international infectious disease control, particularly when compared to the corpus of work produced by historians and those working from political science and international law perspectives. Public health is not an uncommon focus of sociological research, but sociological work addressing public health practices at the global level and particularly at the level of international infectious disease control remains a rarity. We were also surprised by how new practices in international infectious disease control and emergency governance played out against a background of shifting public health concepts and ways of knowing that had not been fully identified or explored by existing research. We wrote this book to respond to these absences and intend it to be a sociological contribution to research on contemporary global public health with an emphasis on the analysis of knowledge relations.

In thinking and writing about knowledge in the context of global public health, our collaboration has created a dialogue between two traditions of inquiry sensitive to the analysis of discourse, concepts, and the formal apparatus of expertise and knowledge: the history of the present (from the work of Michel Foucault) and studies in the social organization of knowledge (from the work of Canadian sociologist Dorothy Smith). While we discuss that dialogue more fully in the following section, we have found that working across these two traditions has made us sensitive to the productivity of knowledge at a social and institutional level. Our analytic stance takes up knowledge as a constituent of the social that shapes how things are done, including how they get done at the level of large-scale relations such as those of global public health. In this book we explore how conceptual shifts and new uses of knowledge have driven change and created new possibilities for action within the technical and political arrangements of what we have come to call ‘global public health emergency vigilance.’

We use the phrase global public health emergency vigilance, or more usually the shorter and less cumbersome ‘global emergency vigilance’ or ‘emergency vigilance’ to conceptualize the object of our study, doing so with an approach that is oriented primarily to the study of knowledge. The goal of global public health emergency vigilance is to recognize dangers to public health, verify information, send alerts, and intervene before a situation becomes internationally catastrophic. In the world on alert for international public health emergencies, the watchful apparatus of emergency vigilance detects the marginal and dangerous event.

Emergency vigilance marks a deep revision in public health reasoning, a reconstruction and displacement of infectious disease control. Global emergency vigilance differs from the previous period of international infectious disease control in its target (main antagonist), goal, relation to the potential, conceptualization of report, temporal modality, and securitization.

International health law in the 20th century targeted infectious diseases, whereas current international health law in force since 2007 targets “international public health emergencies.” International public health emergency includes but is not confined to infectious diseases, instead extending to anything that crosses international boundaries and damages human health at a population level. The public health aspects of chemical, industrial, environmental, and radiological disasters may be international emergencies as indeed may be infectious disease outbreaks of yellow fever or Marburg hemorrhagic fever.

The goal of global emergency vigilance is to contain public health emergencies prior to their spread across international boundaries rather than, as previously, to interrupt the international transmission of infectious diseases after they had crossed an international boundary. Global emergency vigilance aims to detect the wide range of emerging and potential diseases and medical conditions rather than, as was the case throughout the 20th century, actual cases of known diseases. The period of emergency vigilance orients to both the potential and the actual.

The transition to emergency vigilance also transformed the conceptualization of report, both what was to be reported to WHO and who was qualified to do such reporting. Whereas the prior period of international infectious disease control required that national public health officials report to WHO cases of infectious diseases, emergency vigilance requires the reporting of events. Case reports were of disease diagnoses. “Event” is a broader concept that refers to the appearance of a disease or something that “creates the potential for disease;” the concept of “disease” is extended to include both illnesses and medical conditions such as injury (International Health Regulations [IHR] 2005: Definitions). Events are reported not only by sovereign states, but also by online outbreak detection systems and nonstate organizations that draw on unofficial sources of information, such as global health news.

With respect to temporal modality, global emergency vigilance holds itself to a standard of operating in ‘real time;’ public health knowledge is to coincide with the time in which the emergency is occurring to facilitate flexible public health actions. During the previous period, WHO’s knowledge of epidemics did not synchronize with their occurrence. Many epidemics were simply local events unknown to national and international authorities. WHO was often not notified of outbreaks that required report under international law because of the economic consequences of doing so for the country involved. The result was that WHO only became aware of some epidemics long after the initial outbreak.

Lastly, the juridical relations of international public health emergencies have, unlike all previous forms of international health law that applied only to a small number of known infectious diseases, been extended to apply to the public health aspects of accidental and deliberate chemical, biological, radiological and nuclear incidents. Emergency vigilance has thus been securitized in the sense of articulating global public health with international security—the relations across sovereign states together with treaties and institutions that structure the trans-state relations.

Global emergency vigilance is implicated in one of the great political questions of our present: the constitution of a political level beyond national sovereignty. The requirement that emergency vigilance have the earliest possible knowledge of actual, emerging, and potential events challenged the postcolonial flows of public health knowledge, specifically that the ultimate place of power over international infectious disease reporting to WHO was a sovereign matter, and sovereigns could refuse to report with impunity. In the name of a potential/virtual microbial world and heightened detection standards, a new world order in health was fashioned at the turn of the 21st century that emancipated public health knowledge from its subordination to sovereignty and constituted WHO as a power above the sovereign. We argue that global emergency vigilance illustrates the insufficiency of any theory that would reduce the political to either sovereignty or to governance. It is precisely the form of the political beyond both governance and sovereignty that is raised at the site of global emergency vigilance.

Our writing here is intended as a contribution to the understanding of global biopolitics. The concept of biopolitics refers to an historical change—an epochal one—that began in the 18th century and continues to date. In Foucault’s words, “biopolitics”/”biopower” was a “general strategy of power” whereby “starting from the eighteenth century, modern societies took on board the fundamental biological fact that human beings are a species” (Foucault 2007: 1). Global emergency vigilance is biopolitical in this sense because it aims at the conservation of populations and citizens within and across sovereign states. It has a double and inconsistent logic, one of containing emergencies from spreading into the North, but also a cosmopolitan one of securing human health for all the peoples of the world.

This is a theoretico-empirical book in which theory, analysis, and the empirical mutually enable and limit one another, although it begins in the empirical and ends in the theoretical. The central analytic intent of our research is to explore the significance of changes in knowledge for the emergence of a new global public health apparatus. Our topic, global public health emergency vigilance, involves an international apparatus that links human actors, technologies, microbial phenomena, political powers, laws, forms of knowledge, and organizations. We have taken care to give proper due to the complex technical developments and shifts in knowledge represented by global emergency vigilance, but we do so in ways that contribute to our central analytic interest in knowledge as active.

At many times during the writing of this book we were forcefully struck by the commitment among those with whom we spoke to public health for those in the global South and the global North. We deeply respect their work. At the same time, we are keenly conscious of the limitations of and problems inherent in current global public health security, which clearly has been primarily driven by the North. To say this is not to discount the stated positions of public health officials from Asia and Africa who have told us unequivocally that emerging infectious diseases and international public health emergencies are concerns of the South as well as the North. We, however, follow the historian and philosopher Foucault in being more interested in the explication of the dangerous than in judgments of the good and bad.

Global Public Health Emergency Vigilance

We came to the concept of global emergency vigilance after a long process of considering possibilities for a reflexive naming of our object, a process marked by an awareness of how a name shapes what can be thought about a phenomenon and a concern to find a way of writing that would reflect the analytic specificity of the approach we took to our topic. Few alternatives presented themselves to us. In the health sciences literature, for example, commentators are fond of announcing a new era in global infectious disease control but offer no way of analytically specifying that era. They simply distinguish the new from the old by drawing attention to the greater speed of the current system of global infectious disease control or by identifying other characteristics, such as its challenge to state control over information or its uses of unofficial information, that are then taken as self-evidently new without historical comparison. By turns we considered framing our research object as surveillance and post-Westphalian governance before coming to consider it as a vigilance apparatus.

A) Surveillance?

It would have been more conventional to conceptualize our research as investigating surveillance rather than vigilance. However, our focus is not on detection but on the broader field of relations linking the idea of emerging infectious diseases (EID), the technique of outbreak detection, and the invention of a new politico-juridical framework for global public health emergencies. We wish to examine the field of relations across EID, outbreak detection, and international law rather than frame our discussion in terms of outbreak detection as a surveillance form. Second, if we had chosen surveillance as an explanatory category, it would have been conflated with the public health sense of surveillance. We are well aware that social scientific language cannot be fully separated from the language(s) of its research participants; social scientific studies always bear the accent of their research sites. Yet the use of surveillance saturates the speech practices of our empirical site, making it very difficult to separate sociological from public health senses of surveillance. This would have resulted in conceptual incoherence. In this book, ‘surveillance’ will be used in its contemporary public health sense to mean collecting, interpreting, disseminating, and acting on health information by authorities.²

We have also been reluctant to use surveillance as an explanatory category for analytic reasons. Surveillance studies focus on the human subject. Thus, by way of example, the sociologist David Lyon defines surveillance as “ … paying very close attention to personal details—often in the form of digital data—for the purpose of influencing, managing, or controlling those under scrutiny” (Lyon 2003: 15). A great deal of the sociology of surveillance has explored the routine, automated gathering of personal data for marketing and security (private and public; local, national, and international). However, online early warning detection does not track personal data. Nor is it restricted to persons. Early warning outbreak detection orients to what is called the “event” in the WHO International Health Regulations (IHR): “a manifestation of disease or an occurrence that creates a potential for a disease” (IHR 2005: Art. 1). Detection of events extends to species other than the human, to environmental disasters, to nuclear explosions, and to the deliberate spread of pathogens. Event detection does not risk-profile individuals, and if anything it lightens the significance of national borders in order to enhance the international public health control of infectious disease outbreaks. Thus the concept of surveillance provided little help in conceptualizing our object of study.

B) Post-Westphalian Governance?

We secondly considered identifying our research object in the politico-juridical terms suggested by David Fidler. Fidler has reflexively named current arrangements in international infectious disease control as a post-Westphalian system of infectious disease governance. A professor of law at Indiana University, Fidler writes on international disease control from the perspective of international legal policy. His work is prodigious, important, and largely defines the field. Fidler (2004b: 42–68) describes international infectious disease control practices associated with the SARS outbreak as post-Westphalian because of the challenge they pose to the previous political system for international disease control that rested fundamentally on state sovereignty. Westphalia in this context refers to the Peace of Westphalia (1648) that ended the Thirty Years War in Europe (a period of religious strife among Christian sects) by establishing a system of equal sovereigns that exercise absolute power within their territories. The Peace of Westphalia brought a formal end to the Holy Roman Empire when formerly feudal powers were no longer required to owe allegiance to the Pope. Westphalia is acknowledged as the moment of crystallization for the principle of state sovereignty within Europe, constituting an international system of sovereign states and their nonsovereign colonial possessions.

Fidler’s concept of post-Westphalian public health governance analytically privileges the question of state sovereignty. This is an entirely reasonable thing to do, especially for someone writing from an international law and international relations perspective. Challenge...