Should health professionals play the global health security card?
Authors: Stefan Elbe
Journal: The Lancet (2011)

The health of all peoples is fundamental to the attainment of peace and security. So, at least, argues the constitution of WHO drafted more than half a century ago. Recent experience of an epidemic of epidemics has driven home this message. From pandemic H1N1 influenza A and pathogenic avian influenza, through to severe acute respiratory syndrome and the HIV/AIDS pandemic, we seem to have entered an era of deep microbial unease. Perhaps nothing reflects this underlying mood shift more poignantly than the growing tendency to articulate international health policy in the metaphors and vocabulary of security. What began in the year 2000 with the unprecedented step taken by the UN Security Council in designating a disease—HIV/AIDS—as a threat to international peace and security, has become a staple and defining aspect of global health politics in the past decade. The rise of the new health security paradigm has even seen some health issues becoming formally incorporated into national security strategies. But should health issues and security concerns be married in this most intimate of ways? Should health professionals be playing the security card in international politics? That, of course, depends very much on which version of "health security" is under consideration. So far the strongest security card has probably been played by those working in the field of biosecurity and bioweapons. Here, the worlds of health and security collide inescapably because state or non-state groups might deliberately weaponise diseases to achieve political ends. Expert opinion remains divided about the likelihood and extent of such an attack. However, the intentional release of sarin gas in Tokyo's subway system by the Aum Shinrikyo cult in 1995 represented an early warning sign. That was a chemical attack, but the release provoked wider fears about the possibility of future biological attacks. The terrorist attacks of Sept 11, 2001, and the "anthrax letters" posted to prominent addresses in the USA just a month later, only added to those concerns. Playing this security card has certainly proved influential in terms of freeing up resources and galvanising leadership. Biosecurity arguments formed the impetus behind the creation of various national initiatives and research bodies on both sides of the Atlantic, as well as the formation of the Global Health Security Initiative—an informal, international partnership of states seeking to strengthen their response capabilities in relation to the threat of biological, chemical, and radionuclear terrorism. Yet that does not mean the biosecurity community has had an easy ride. Public health experts have vocally and repeatedly pointed to the uncomfortable tension between the fundamentally different professional cultures that exist between public health communities, on the one hand, and security and counter-terrorism communities, on the other. Occasionally, this clash of cultures has provoked discussions within WHO about the extent to which an international organisation devoted to public health can become involved in responding to bioweapons incidents without undermining its perceived neutrality and objectivity. Others have questioned whether recourse to the security card to raise resources is a good thing in and of itself. Surely it is not just the volume of resources that matters, but also the balance of how those resources are allocated. Here further concerns have surfaced about the perceived narrowness of much biosecurity funding and its uncertain contribution to wider public health objectives. Playing the biosecurity card, in short, has proved a double-edged sword. A somewhat different security card has been played by those working within the framework of national security. Here the focus has been predominantly on the threat posed by naturally emerging and re-emerging infectious diseases in the context of an increasingly globalised and interdependent world economy. This case for linking health and national security is strong in that a naturally occurring infectious disease could be just as damaging as an attack by a foreign power in terms of causing significant morbidity, mortality, and economic disruption. It is a case backed up by an influential national intelligence estimate produced by the US National Intelligence Council. The Global Infectious Disease Threat and Its Implications for the United States found that since 1973 at least 30 previously unknown disease agents have been identified, and that during that same period at least 20 older infectious diseases have re-emerged, frequently in drug-resistant form. The case tends to be all the more persuasive because the widespread perception of microbes as "invaders" coming from "outside" maps neatly onto a pre-existing idea of national security involving the protection of populations against external threats. To be sure, such a national security framing of infectious diseases has distinct policy advantages as well. Bringing the dramatic connotations of security into play helps garner political attention and lubricates the flow of resources for tackling these issues. Both of those things are necessary if countries around the world are to be prodded into creating—and maintaining—effective pandemic preparedness plans. But none of this has shielded the health security framework from controversy either. Although many developing countries are just as keen to protect their populations against future pandemic threats as their western counterparts, some have voiced concerns about how more powerful states might use—or even abuse—the imperatives of "security" to override their country's political sovereignty in times of an international public health crisis. Unlike much of the technical language used by health professionals working internationally, "security" is a politically deeply charged and sensitive notion—the pursuit of which has in the past enabled states to override legal constraints and justify a range of extraordinary and also controversial practices. Not surprisingly, playing the national security card in relation to pandemic threats has bred considerable apprehension and distrust in some quarters. It too, in other words, has proved a double-edged sword. There is still plenty of space, then, in the market place of health security ideas for a third—and altogether different—security card to be played by those working with a broader notion of human security. The human security advocates seek to recalibrate security practices around the needs of individuals rather than just of states, and have been just as keen in that vein to harness the idea of security for their global health efforts. Within the human security framework, the premature loss of life caused by disease continues to represent one of the greatest threats to people around the world. Moreover, in many low-income countries it is not so much the spectre of armed conflict or bioterrorism that constitutes the greatest security threat for most people, but rather the absence of more effective and affordable health care. In this framework, the most pervasive threats to security are not seen to emanate from those acute and highly infectious diseases that can spread rapidly between countries, or those that could be deliberately released by a terrorist group; they stem instead from a range of illnesses that remain endemic in many low-income countries hampered by a weak public health infrastructure—for example, malaria, tuberculosis, and HIV/AIDS. Hence human health security is not principally concerned about future pandemics, but about already existing endemics, especially in the developing world. One of the greatest policy advantages of this idea of human health security is that—comparatively—it has courted much less political controversy among health professionals. It is true that difficult questions remain about the operational utility of the concept. After all, the human security framework works in broad brush strokes and adopts a logic that renders virtually any lethal disease (including non-communicable diseases) a credible security threat. But where, then, should health rank in relation to all the other pressing human insecurities, like threats to economic security, food security, environmental security, and so forth? And exactly which global health issues should be prioritised? There is concern that many human health security initiatives have tended to reflect the priorities of wealthy donors, rather than being closely matched up to the health conditions and priorities on the ground. That said, it certainly remains the case that the much softer connotations of the human security approach seem to have largely escaped the feelings of disquiet and concern provoked by the other two security cards. That is no doubt a substantial achievement, but one which has a political flip side as well: the human security approach seems to have been less effective in mobilising wider political support and freeing up designated resources than the previous two. The distance that still needs to be travelled to achieve the health-related Millennium Development Goals is testament to that more limited legacy. Although playing the human health security card is much less of a double-edged sword for health professionals, perhaps it is not much of a sword in terms of galvanising attention, leadership, and resources for public health. That must give pause for thought. In the end, health professionals are left with a difficult challenge with regard to the new health security paradigm. Yes, marrying health issues to security concerns can do much in terms of harnessing political leadership and resources for various international health issues. But playing the security card also has a range of unintended side-effects in terms of orienting the global health agenda around a fairly narrow set of diseases, and ones that tend to reflect the current priorities of western governments. The deeper challenge for the health security paradigm is, I would suggest, how best to ensure that a sound balance between all three versions of security is maintained. How, in a time of increased pressure on budgets, can the merging of global health and security maintain high levels of resources and leadership for global health, without encouraging the neglect of those health concerns that predominantly affect developing countries? To stick with the metaphor at hand, health security advocates will have to play with a full deck if the notion of health security is to remain a meaningful framework for improving global health in the 21st century.