Routledge Handbook of Global Health Security

Simon Rushton, Jeremy Youde

• Publisher: Routledge
• Year: 2014
• ISBN:
  9781136155567
• Edition: 1
• Topic: Politics & International Relations
• Subtopic: Social Policy
• Index: Politics & International Relations

This new Handbook presents an overview of cutting-edge research in the growing field of global health security.

Over the past decade, the study of global health and its interconnection with security has become a prominent and rapidly growing field of research. Ongoing debates question whether health and security should be linked; which (if any) health issues should be treated as security threats; what should be done to address health security threats; and the positive and negative consequences of 'securitizing' health. In academic and policy terms, the health security field is a timely and dynamic one and this handbook will be the first work comprehensively to address this agenda.

Bringing together the leading experts and commentators on health security issues from across the world, the volume comprises original and cutting-edge essays addressing the key issues in the field and also highlighting currently neglected avenues for future research. The book intends to provide an accessible yet sophisticated introduction to the key topics and debates and is organised into four key parts:

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• Health Securities: the fundamental conceptual issues, historical links between health and security and the various ways of conceptualising health as a security issue

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• Threats: those health issues which have been most frequently discussed in security terms

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• Responses: the wide range of contemporary security-driven responses to health threats

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• Controversies: the securitization of health, its impact on rights and justice and the potential distortion of the global health agenda

This book will be of great interest to students of global health security, public health, critical security studies, and International Relations in general.

Part I
Health securities

1
The Many Meanings of Health Security

Colin McInnes

The link between security and health is not new, but has traditionally been seen in narrow, albeit bidirectional, terms: the manner in which disease may affect military capacity and especially military operations and the impact of conflict on health and health care. By the turn of the millennium, however, this link was broadening and its significance to national and international agendas rising. The rationale for this was constructed along fairly consistent lines: that new global health risks had appeared as a result of emerging and reemerging diseases, increased population mobility, spreading transnational crime, environmental change, and bioterrorism; and that these posed new security dangers (see for example Brundtland 2003; CIA 2000; WHO 2007c; Yuk-ping & Thomas 2010). Moreover, this was a period when security audiences had been sensitized to the idea of new risks following the “bonfire of the certainties” at the end of the Cold War. The attempt to construct health as a security issue (to “securitize” it) therefore fell on more fertile ground than might previously have been the case. Beyond “real world” concerns, however, were political considerations, with some within the public health community recognizing that the security label was a potentially effective means of elevating global health issues on the national and global stage.

“Security,” however, is not a straightforward concept but “essentially contested” – that is, a concept that generates unsolvable debates about its meaning and application (Buzan 1991: 7). This chapter focuses on four terms widely used in debates over health security in this global context. It does this to illustrate how health security is similarly essentially contested. These terms are global (public) health security, national security, human security, and biosecurity. Crucially the chapter suggests that these are not mutually transferable terms but have different implications both for the range of health issues involved and for whose security is at risk. The meaning of each term is constructed for a particular purpose including promoting a certain agenda and privileging certain interests over others. The object of this chapter, therefore, is not to suggest that there are criteria whereby a health issue may or may not be considered a security issue or that there is a single agreed definition of health security when used in the global context. Instead, it is to reveal how, like other forms of security, it is essentially contested and not amenable to a single set of agreed criteria. The lack of an agreed definition is not due to lack of effort but because in its different uses and terms it reflects different interests and agendas.

National and international security

National security is often characterized in a narrow manner: that the referent object of security is the state; that the main concerns are direct threats, usually military in nature; that the context is one of an anarchic international states system where self-help is the order of the day; and that stability (both state and international) is privileged over issues such as rights and justice. Security therefore depends on the state protecting itself from threats, and a social contract is entered into whereby citizens forsake some of their individual freedoms to secure the greater collective good. The risk, however, is that the social contract is undermined by the increasing power of the state, which may become willing to sacrifice the freedoms and rights of the people it is supposed to protect in order to preserve its own power. It is this fear that has led to many health practitioners – concerned with protecting and promoting the well-being of individuals and communities – to be wary of national security.

National security’s traditional focus on military threats however has been replaced by a more diverse range of risks. This broadening of the security agenda has created a space where issues such as health can be considered part of national security. But understandings of the state and state power have also changed. Of particular significance for health security is the shift away from sovereign power and towards governmentality. Drawing on the work of French philosopher Michel Foucault, both Stefan Elbe and Alan Ingram have argued that power is no longer oriented self-referentially towards preserving the power of the state (sovereign power) but rather towards improving the welfare of citizens (governmentality). Both Elbe and Ingram accept that this shift applies predominantly to Western states; but as these states have set the agenda for health security, the significance is considerable (Elbe 2009: 86–107; Ingram 2010).

National security’s interest in health has been longstanding in that the physical condition of military troops affects their operational performance. Diseases such as cholera and dysentery have historically caused significant numbers of casualties during military campaigns. From the late 1990s on, however, interest in a broader range of health concerns began to develop within a number of key policy circles. In so doing, the foreign and security policy community maintained a robustly state-centric approach in prioritizing the national interest and international stability when discussing health security issues (for example Cook 2000: 2; Downe 2003; FCO 2003: 13; U.S. State Department 2004: 76). Two examples of this are the 1999 U.S. National Intelligence Estimate on the global threat of infectious disease to the United States and the January 2000 meeting of the UN Security Council. On the first, in 1999 the Central Intelligence Agency (CIA) identified a number of risks to U.S. security arising from infectious disease, risks exacerbated by rapid globalization and the increased worldwide movement of goods and people. These included not only risks to U.S. citizens traveling abroad but to citizens at home given the potential for certain infectious diseases to spread globally. Crucially, however, the CIA went further than this, arguing that infectious disease also posed a risk to international stability and even economic growth, thus placing it firmly in the territory of national security (CIA 2000). On the second, at its first meeting of the new millennium, the UN Security Council discussed the threat of HIV/AIDS to Africa and, in Resolution 1308, warned “that the HIV/AIDS pandemic, if unchecked, may pose a risk to stability and security” (UNSC 2000a; see also McInnes & Rushton 2010; UNSC 2000b). In particular, the Security Council drew attention to the effects of HIV/AIDS on social stability and on peacekeeping missions. In both the interests of the state appeared paramount, whether in terms of stability or the protection of its citizens or soldiers (peacekeepers).

Three issues have dominated national security’s interest in and engagement with health: acute and severe infectious diseases of epidemic potential; HIV/AIDS; and bioterrorism (for an overview, see McInnes 2012). What is missing, however, is a rationale as to why some health issues might be considered national security problems but not others. Health issues are not identified as national security risks by reference to an explicit set of criteria but rather have arisen in an ad hoc manner and been agreed to intersubjectively by key national and international actors. Although it is possible to identify three broad sets of reasons suggesting an implicit agenda, these are also problematic, as will be seen below. The first of these reasons is the potential of a health issue to threaten international stability. Four possible arguments can, in turn, be identified as supporting this:

1. Health crises may have dramatic effects on the global economy. That health crises may have detrimental economic effects has been long understood. Globalization has not only increased this sensitivity but has also broadened the geographical territory potentially affected. An epidemic may lead to reduced economic growth in areas not directly affected by the disease or even in worst case scenarios trigger a global recession, increasing levels of poverty and creating stresses on lifestyle and livelihood amongst even the wealthy states.
2. Poverty and poor health may lead to migration as people seek a better, safer life elsewhere. Migration flows risk spreading disease and may act as destabilizing forces in a region.
3. Militaries may be at increased risk from some diseases, such as HIV/AIDS, impacting upon their operational capabilities with potential effects on national security and thereby international stability.
4. Finally, risks from certain diseases (and in particular HIV/AIDS) may affect the willingness of states to send troops on peacekeeping missions. Concerns have also been expressed at the willingness of countries to receive peacekeepers if they fear that troops may bring high rates of HIV infection into a country with them.

The problem with these four arguments is that the causal relationship between an adverse health effect and international stability is questionable, and/or the empirical evidence to support the claim is suspect or missing. For example there is no credible evidence that international stability is affected by the macroeconomic effects of health crises. Neither sudden outbreak events such as SARS and pandemic influenza nor chronic diseases such as malaria and (increasingly) HIV/AIDS have affected international stability because of their macroeconomic effects; nor have SARS and pandemic influenza demonstrated significant long-term macroeconomic effects. Similarly, although there is an awareness of migration as a security issue (for example, see Huysmans 1997; Weiner 1992–1993; in contrast see Graham & Poku 2000), health status does not appear to be a key driver in people leaving their homes. Rather, poverty, famine, and conflict appear to be much more significant causes of mass migration. Although there was some evidence in the early years of the millennium that militaries were more susceptible to HIV infection, the empirical evidence is no longer so clear cut, while HIV/AIDS awareness campaigns have helped to reduce the risk of infection (ASCI 2009; McInnes 2006). Equally, the link between a military weakened by disease and state instability/insecurity is also unclear and lacking empirical evidence, while research on the global spread of HIV/AIDS does not support the argument that peacekeeping is an important vector in the transmission of the disease or that peacekeepers are especially susceptible (UNAIDS 2005; UN DPKO 2005).

The second broad set of reasons offered as to why health issues might be a national security problem concern their ability to affect the internal security of a state (see for example CIA 2000; ICG 2001). If the domestic economy is damaged, then divisions between rich and poor may be exacerbated. Increased levels of poverty may, in turn, breed social discontent and provide a fertile ground for entrepreneurs of violence. Moreover, confidence in the government, or in the state more generally, may be damaged if public health services are unable to cope. What is again lacking, however, is the empirical evidence to support these arguments. With HIV/AIDS, in particular, a number of states have had very high levels of infection for more than a decade, especially in sub-Saharan Africa. These are also among some of the poorest countries on earth. Yet there is little evidence to date that high HIV/AIDS prevalence has created destabilizing pressures threatening the security of the state.

The third set of reasons concerns high morbidity and mortality rates. When the number of people at risk reaches exceptional levels, then this moves into the realm of national security, both because of the responsibility of the state to protect its citizens and because the effective operation of the state may be at risk. The level at which an event becomes sufficiently extraordinary to be considered a security issue, however, is not definable for example as a percentage of the population; rather it is determined intersubjectively on a case-by-case basis. But a key feature, for the purposes of this section, is that the cause can be represented as an exogenous threat. Three health issues seem both to meet this necessary condition of externality and breach the threshold of being outside the ordinary: the spread of existing diseases such as Ebola or West Nile virus to new geographies; the emergence of new, potentially pandemic, diseases such as SARS or a novel strain of influenza; and bioterrorism. Of these, probably only the second has the potential to kill very large numbers of people within a state. But it is not only the level of morbidity that matters, but the sense of risk felt within high-income countries. Thus in the 1990s, when the Ebola virus first appeared in the United States, the level of concern and attention far outran what might have been assumed from the number of people realistically at risk from the disease (see for example CIA 2000; Garrett 1994). Similarly, concerns over bioterrorism may be overstated with doubts over how easy it is for sub-state groups to gain access to, or produce, effective weapons and over how easy it is to use them in a manner that might cause significant loss of life. But this does not mean that the threat is not considered to be very real and of high political salience, resulting in substantial resources being allocated to allay those fears (see for example Graham 2008).

Global public health security

The term global public health security (sometimes abbreviated to global health security) is largely associated with the WHO and its interest in how risks to public health have been globalized (e.g., Baker & Forsyth 2007; Rodier 2007; WHO 2002). Although the impact on public health is not WHO’s only concern here – “global health security, or lack of it, may also have an impact on economic or political stability, trade, tourism, access to goods and services and, if they occur repeatedly, on demographic stability” (WHO 2007c: 1) – it is the main focus. In its 2007 World Health Report (WHO 2007c), WHO discussed its understanding of global health security explicitly in terms of public health security. For the WHO, “Public health security is defined as the activities required, both proactive and reactive, to minimize vulnerability to acute public health events that endanger the collective health of national populations. Global public health security widens this definition to include acute public health events that endanger the collective health of populations living across geographical regions and international boundaries… [it] embraces a wide range of complex and daunting issues, from the international stage to the individual household, including the health consequences of human behaviour, weather-related events and infectious diseases, and natural catastrophes and man-made disasters” (WHO 2007c: 1).

The background document accompanying the 2007 World Health Report provides a list of eight health security issues as identified by WHO: emerging diseases; economic stability; international crises and humanitarian emergencies; chemical, radioactive, and biological terror threats; environmental change; HIV and AIDS; building health security; and strengthening health systems (WHO 2007b: 3). This list, and the manner in which WHO then describes each of the issues, is important to this chapter because it reflects a perspective of health security as being primarily a public health concern rather than, for example, a threat to the state. More generally, WHO’s identification of global health security risks may be placed into three somewhat broad catego...

Table of contents

• Cover Page
• Half Title Page
• Title Page
• Copyright Page
• Contents
• List of tables and figures
• Notes on Contributors
• Introduction
• Part I Health securities
• Part II Threats
• Part III Responses
• Part IV Controversies
• Select Bibliography
• Index