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- Herausgeber: John Wiley & Sons
- Kategorie: Geisteswissenschaft
- Sprache: Englisch
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.
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Veröffentlichungsjahr: 2019
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Table of Contents
Cover
Title page
Copyright page
Acknowledgements
Introduction: Disease and Security in Historical Perspective
Disease, History and International Relations
Disease, Politics and Scientific Progress
Disease, the Individual and the State
The Threat of the ‘Other’ and the Need for International Responses
Chapter Outline
Note
1
:
Pandemics and Global Health Security
Epidemics and Pandemics
Global and National Health Security
Border Controls and Global Health Security
History, the Future and the Global Health Security Narrative
Conclusion
Notes
2
:
AIDS: A Positive Case of Securitization?
The Construction of AIDS as a Security Threat
Risky People and Threatening Communities
Activism and Resistance
Conclusion
3
:
Science, Risk and Uncertainty
Biological Weapons, Bioterrorism and Biodefence
Laboratory Escapes and Scientific Misadventures
Homebrew Biotechnology
Conclusion
Notes
4
:
Disease, Human Rights and Security Responses
Disease, Security, Borders and Rights
Human Rights, the Siracusa Principles and Domestic Outbreak Response
The Right to Health: Prevention, Treatment and Control
Conclusion
Note
5
:
Global Inequalities and Differential Disease Risks
Inevitable and Shared Global Risks
Delivering Global Health Security: Surveillance and Containment
Addressing Inequalities for Global Health Security?
Conclusion
Note
6
:
Everyday Insecurities, Health Priorities and Global Agendas
Preparedness and Opportunity Costs: The Case of Stockpiling
Everyday Insecurities and the Global Health Security Agenda
The Wider Global Health Agenda: Towards Development and Human Security?
Insecurity, Globalization and the Meaning of ‘Global Health’
Conclusion
Note
Conclusion: Towards a Pro-Health Politics
Security, Dignity, Solidarity
Against Depoliticization: Towards a Pro-Health Politics
References
Index
End User License Agreement
Guide
Cover
Table of Contents
Begin Reading
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Security and Public Health
Pandemics and Politics in the Contemporary World
Simon Rushton
polity
Copyright © Simon Rushton 2019
The right of Simon Rushton to be identified as Author of this Work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988.
First published in 2019 by Polity Press
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All rights reserved. Except for the quotation of short passages for the purpose of criticism and review, no part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the publisher.
ISBN-13: 978-1-5095-1588-2
ISBN-13: 978-1-5095-1589-9(pb)
A catalogue record for this book is available from the British Library.
Library of Congress Cataloging-in-Publication Data
Names: Rushton, Simon, 1978- author.
Title: Security and public health : pandemics and politics in the contemporary world / Simon Rushton.
Description: Cambridge, UK ; Medford, MA : Polity, 2019. | Includes bibliographical references and index.
Identifiers: LCCN 2018050591 (print) | LCCN 2018053158 (ebook) | ISBN 9781509515929 (Epub) | ISBN 9781509515882 (hardback) | ISBN 9781509515899 (pb)
Subjects: | MESH: Pandemics–prevention & control | Communicable Disease Control | Politics | Global Health
Classification: LCC RA566.27 (ebook) | LCC RA566.27 (print) | NLM WA 110 | DDC 362.1969/8–dc23
LC record available at https://lccn.loc.gov/2018050591
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Acknowledgements
In thinking about the politics of health security, I have benefitted hugely from the knowledge, insights, ideas and support of a number of friends and colleagues. I owe particular debts of gratitude for countless conversations and their inspiring work over many years to Emma-Louise Anderson, Garrett Wallace Brown, Sara Davies, Alexia Duten, Stefan Elbe, Christian Enemark, Adam Ferhani, Pieter Fourie, Sophie Harman, David Heymann, Steven Hoffman, Alison Howell, Yanzhong Huang, Adam Kamradt-Scott, Maria Kett, Sonja Kittelsen, Kelley Lee, Catherine Yuk-ping Lo, Chris Long, Colin McInnes, João Nunes, Colleen O’Manique, Gorik Ooms, Amy Patterson, Andrew Price-Smith, David Reubi, Stephen Roberts, Anne Roemer-Mahler, Adam Schiller, Jeremy Shiffman, Frank Smith III, Michael Stevenson, Preslava Stoeva, Nick Thomas, Rachel Thompson, Remco van de Pas, Clare Wenham, Owain Williams and Jeremy Youde. I am indebted to all of them – and to all of the others who I embarrassingly forgot to include in the list.
I have also been privileged to be part of some of the most interesting and most nurturing groups of scholars, including the Global Health groups of the International Studies Association, the British International Studies Association and the European International Studies Association, as well as the Centre on Global Health Security at Chatham House. Long may they prosper.
Thanks to the editorial team at Polity Press, especially Louise Knight, Sophie Wright and Nekane Tanaka Galdos, for their support and their patience.
Most of all, I would like to thank all of the students in the Department of Politics at the University of Sheffield who have taken my module Pandemics and Panics: Health, Security and Global Politics since it first ran in 2013. I have learned a lot from my conversations with them, and many of the hard questions and interesting cases that we've worked through together have found a home in these pages. This book is dedicated to them.
Introduction: Disease and Security in Historical Perspective
This is a book in defence of politics – a word that often has only negative connotations. Practitioners and policymakers in medicine and public health frequently see ‘politics’ as an obstacle that needs to be circumvented. They bemoan the fact that politics gets in the way of attempts to tackle global health crises: governments either have other interests that they choose to prioritize over health (e.g. Hooker et al. 2014), or lack the necessary ‘political will’ to take decisive action (e.g. Foege 2000). Because of politics, governments fail to cooperate internationally to prevent, detect and control outbreaks (e.g. Kluge et al. 2018). Politics, we often hear, distorts efforts to make health policies truly evidence-based (e.g. Florin 1996). All of these complaints are often true. So why defend politics? In this book, my argument is that politics can be a problem, but it is not only a problem – and not inevitably so. Although the ideal for many is to exclude politics from the health policy process, instead moving forward by ‘finding out what works’ and then ‘getting it into policy and practice’ (Barnes and Parkhurst 2014: 159), it is only through politics that the deficiencies with current responses to disease crises can be challenged and rectified. Our current failure to adequately protect populations from disease makes politics moreimportant, not less. Only by engaging with politics, not turning away from it, can progress be made.
One of the causes of these varying views of the value of politics is differences in what we mean by the term. If we understand politics in a narrow sense, as the activities of governments and other agencies of the state, then current failures are indeed products, to a great extent, of politics. More expansive and critically-oriented definitions of politics, however, are less top-down in nature, focusing instead on the variety of ways in which power structures relationships and seeing a wide variety of actors as able to exercise power through engaging in political acts of various kinds (Bambra, Fox and Scott-Samuel 2005: 190). It is this more expansive view of politics that allows for politics to be a route to change, and that sees politics as a potentially productive rather than merely a restrictive force.
Security, my focus in this book, is a particular kind of politics, but it does not exist in a separate universe to other political considerations. Security policy is often seen as a particularly top-down manifestation of politics – although in this book I will also show the centrality of ‘bottom-up’ politics to resisting some of the downsides of a security-driven approach to infectious disease, and the role that scientists and other experts not normally thought of as political actors have played in getting disease onto security agendas.
In the field that has come to call itself ‘global health’, we have spent almost two decades debating whether or not diseases should be viewed as threats to national and international security. Attention has focused on whether ‘playing the security card’ is a good political strategy, making it more likely that high-level political attention and serious resources will be devoted to tackling global health problems, or whether securitization is dangerous, generating authoritarian and emergency-driven responses that fail to tackle the underlying causes of vulnerability (Elbe 2011).
All of these arguments are covered in this book, but my starting point is that the securitization ship has already sailed. Most Western governments now have infectious diseases well-established on their security policy agendas, with ministries of defence and homeland security, as well as intelligence agencies, working alongside ministries of health to detect, track and respond to outbreaks. What is more, this can no longer be dismissed as solely a preoccupation of developed countries, although it is in the Global North that it is most firmly rooted. The World Health Organization (WHO) routinely talks about ‘global health security’. The US-led Global Health Security Agenda has (as of May 2018) 65 member countries drawn from every region of the world. The salient questions now are not whether diseases should or should not be securitized, but rather how, politically, security-driven objectives can be reconciled with other important and desirable goals so that we can avoid the downsides of securitization, whilst capturing its upsides. My aim in this book is to move away from what have often been binary discussions over whether or not disease should be securitized towards a discussion of some other, more nuanced, questions:
1.
‘How much’ security do we feel we need from infectious disease threats, given that in a globalized world we can never be 100% secure?
2.
What are we prepared to sacrifice to get the level of security from disease that we desire? Are we willing to bear substantial economic costs? Are we willing to give up some rights and freedoms? Where else might we need to make trade-offs?
Clearly these are questions that will attract a wide range of answers, differing between individuals and between cultures and societies. Government policies may or may not reflect the collective views of their citizens on such questions. Here, I seek to add to current accounts of the contemporary politics of health security by investigating the ways in which policymakers attempt to strike balances between responding to perceived security threats and protecting other values and interests. While being alert to the dangers of securitization, I show in the chapters that follow that securitization does not always produce undesirable outcomes, and that a pragmatic approach is needed to ‘understand when security is good or bad in a particular situation’ (Nyman 2016: 832). In some of the cases that I examine in this book, I argue that policymakers have got the balance wrong – going too far, or not far enough, to protect us from disease. Sometimes, security-driven actions have even increased insecurity. Elsewhere, however, securitization does appear to have delivered some tangible benefits. Such judgements are inherently political, inviting contestation over how we do and how we should respond to infectious diseases. Through such debates, politics can be productive. We have no better way of moving towards the right answers than engaging in debate over them.
Some securitization theorists might be sceptical of this view of the politics of security policymaking. According to the classic ‘Copenhagen School’ framework of securitization (Buzan, Waever and de Wilde 1998), establishing something as a national security threat lifts it ‘above’ politics, enabling policymakers to break free of the rules of political process that would otherwise bind. In the chapters that follow, I challenge this idea. I argue that in practice we see governments attempting (sometimes successfully, sometimes not) to strike a balance between security and their other perceived interests. The ways in which these balances come to be struck (for better or worse) are deeply political. I show that security considerations do not always determine the outcome of particular policy debates, and that security-driven responses have been successfully challenged through opposition both within and outside formal political processes.
In contrast to much work in the tradition of the Copenhagen School, this entails refuting the idea that securitization is a binary condition in which a particular threat either is or is not securitized, and which assumes that where securitization is successful, security will trump ‘mere politics’. Instead, I treat ‘security’ and ‘normal politics’ as two ends of a spectrum, with particular threat perceptions and policy responses, such as those examined in this book, more commonly existing at some point between those two extremes (Abrahamsen 2005; McInnes and Rushton 2013). The question that the book poses in terms of securitization is not, therefore, whether or not security logics now dictate responses to infectious diseases, but rather:
3.
What are the conditions under which security logics prevail, and when might other (non-security) interests and objectives determine policy outcomes instead?
Although the majority of this book focuses on the contemporary politics of disease and security, in this introductory chapter I set those discussions in their historical context – and in doing so highlight a number of themes that continue to be central to contemporary policy debates around how we secure populations from disease, how far we should go in attempting to do so, and what sacrifices we are prepared to make in pursuit of greater ‘health security’.
Disease, History and International Relations
International Relations scholars were surprisingly late in coming to recognize the global politics of disease. I say this is surprising because, as is examined in the following sections of this chapter, infectious diseases have been threats that all societies through history have faced, and governments have long sought to put in place measures to protect populations from their devastating impacts. It is also true that the global nature of contagion – and the need to act internationally to successfully control the cross-border spread of disease – was recognized long ago, at least a century before the creation of the World Health Organization which now attempts to live up to the task of coordinating international efforts to prevent and control outbreaks. Pathogens, then, were a source of insecurity long before International Relations scholars began to study them, even if they were less commonly spoken of by policymakers in explicitly ‘security’ terms.
It was only from the turn of the millennium that International Relations began to pay real attention to the relationship between disease and national and international security. Andrew Price-Smith (2001), Stefan Elbe (2003), David Fidler (2003a, 2003b), Kelley Lee and Colin McInnes (2003) and Christian Enemark (2005), amongst others, made particularly noteworthy early interventions in the field. Gradually, research on the global politics of disease has moved from the extreme periphery of the discipline to, if still not exactly central, at least occupying a recognized place within it. University courses with titles like ‘Contemporary Security Challenges’ now routinely include consideration of disease. Mainstream security textbooks feature chapters on it.
This has been an area in which epidemiological events, policymaking and academic analysis have developed alongside one another. The UN Security Council's discussions on AIDS in 2000, at a time of widely proclaimed crisis in the development of the pandemic, were a key moment both in illustrating to policymakers that disease could (and some thought should) have a place on security policy agendas, but also in convincing scholars that the concepts and tools of International Relations could profitably be brought to bear on health issues. It was natural, then, that much of the early scholarship focused on AIDS, and then on a series of subsequent disease crises that were explicitly dealt with by governments in security terms, from Severe Acute Respiratory Syndrome (SARS) to H5N1 (‘bird flu’) to H1N1 (‘swine flu’) to Ebola.
Because it has become more prominent on the agendas of security policy actors in recent years, there has often been a tendency to see disease as a new security challenge – something that came onto the scene only once the Cold War was safely behind us and policymakers began to take a broader view of threats to national security. There is some truth in this. But saying that something is (relatively) new on mainstream security policy agendas is not the same as saying that the threat itself is new. In the remainder of this chapter, I discuss the fact that disease is one of the oldest threats that societies have faced, and argue that it is important to engage with that social, political and economic history of disease, both the continuities and the discontinuities, to gain an understanding of contemporary policy dilemmas and approaches. First, I discuss the fact that societies have always been challenged by disease threats and that over time they have developed new ways of responding to disease that have been driven not only by scientific progress but also by political developments. Second, I argue that providing citizens with some degree of protection against disease (in other words, of viewing disease as a threat to be defended against, rather than an inevitable and unavoidable fact of life) has not just been ‘on the agenda’ of governments, but has been fundamental to the development of ideas about what government is for. The emergence of the modern state has gone hand-in-hand with its attempts to provide for public health, and populations have increasingly come to seek and expect protection against ‘invading’ microbes. Third, I show how the construction of, and action on, disease threats has long had an international dimension. Disease has often been associated with the threat posed by the ‘other’ beyond our borders, and states (especially European states) have historically engaged in international cooperation on cross-border disease control in order to keep themselves safe. To declare, as the UK government did in 2011 (HM Government 2011), that ‘Health is Global’ was a statement of long-standing historical fact, not a claim about a new twenty-first-century reality.
All of this illustrates the fact that, whilst infectious disease is a relatively new concern of academic International Relations, it is not a new concern for those engaged in the conduct of international relations. Legacies of colonial-era health and ‘tropical medicine’, and of almost two centuries of regular diplomatic engagement on disease control, show that, in various ways, disease has long been an international political issue. The contemporary policy questions and dilemmas with which this book is primarily concerned have roots that stretch far back into that history.
Disease, Politics and Scientific Progress
Short of living in a hermetically sealed bubble, humans can never be entirely safe from the threat of infection. The same is true of nations: whilst in theory a state could seal its borders and dramatically reduce the chances of an infectious disease not already present from entering, in reality no country in the modern world is able to achieve this level of isolation – and even if it could, the downsides would almost certainly outweigh the benefits. Discussions of the transnational nature of contemporary infectious disease threats frequently revolve around globalization (Cockerham and Cockerham 2010; McMurray and Smith 2001), but whilst globalization-related changes have no doubt sped up the movement of pathogens around the world, such movement was always a reality of life on earth. For thousands of years, societies have been impacted by outbreaks of infectious disease originating beyond their borders, and for thousands of years they have sought to mitigate their effects (Hays 2009).
In his 2009 book Contagion and Chaos, Andrew Price-Smith (2009: chapter 2) provided a compelling historical account of the various ways in which infectious disease has acted as a ‘stressor’ on societies. Examining a series of epidemics over the course of recorded history, Price-Smith showed that pathogens have challenged societies in ways that go far beyond the obvious effects of morbidity and mortality. These challenges have included inducing political and social instability (in extreme cases even contributing to the collapse of entire civilizations, as with the Amerindian societies devastated by smallpox), causing migration as people attempt to ‘get out of harm's way’, undermining economies, and playing a part in determining the course of armed conflicts.
As Price-Smith also notes, as well as posing direct challenges to social, economic and political stability, epidemics have often exacerbated underlying social tensions, with particular ethnic groups or social classes, for example, being blamed for the introduction of a disease into a population. As will be discussed later in this book, the politics of blame remains a potent feature of contemporary disease politics, with certain groups either explicitly or implicitly being seen as posing a risk to the rest of us. In some cases, such blaming reflects a genuinely increased likelihood of infection amongst certain groups (although whether this makes those people ‘perpetrators’, ‘victims’ or something else is a highly politicized question); in others, blaming tells us far more about societal prejudices than about epidemiology.
Our collective cultural memories of disease also deeply condition the ways in which we see and interpret new and future pathogenic threats. The ‘Spanish’ influenza outbreak which followed the First World War, for example, has become a touchstone for discussions of current and potential future influenza pandemics. The ‘swine flu’ pandemic of 2009 (discussed in chapter 1) came to be written off as mild in comparison to Spanish flu, whilst the potential that a new mutation of the influenza virus could lead to the emergence of a strain as deadly as Spanish flu raises concerns about future security risks, generating terrifying epidemiological projections and huge estimates of potential global mortality. The plague has similarly become a potent cultural marker of death and destruction, especially in European societies. Susan Sontag noted that AIDS in the 1980s was often discussed through the metaphor of plague (Sontag 1989). The same metaphor has been deployed in relation to a huge range of other social and political challenges, from drug abuse (Reinarman and Levine 1989) to Soviet communism (Hoover 2011: section 1). Our collective understandings of historical disease outbreaks condition how we view the world – not least how we respond to contemporary disease threats, calculate future risks and prepare to face them. As João Nunes (2014: 83) has aptly put it, ‘historical examples of death and turmoil caused by disease function as repositories of meaning for interpreting present outbreaks.’
Improvements over time in knowledge and understanding about the causes of disease have, naturally, profoundly shaped the ways in which societies have sought to defend themselves. New developments continue to do so. And although it is tempting to view ourselves as living close to the pinnacle of scientific and medical advancement, it seems certain that our descendants in centuries to come will look back on the twenty-first century as an era in which understanding was limited (and in some cases wrong) and a time when attempts to protect individuals and societies from infectious diseases were unimaginably, perhaps even laughably, primitive. It is certainly common enough for us to look back on earlier historical periods in just such a way. The carrying of posies to ward off disease or the belief that tobacco offers protection against infection seem to us to be hopelessly misguided efforts at preventing illness. Perhaps more surprising, though, is the extent to which previous generations adopted response measures that were relatively effective, despite a lack of accurate scientific knowledge about the underlying causes of disease. Many of our contemporary methods of responding to outbreaks have long historical antecedents. The development of quarantine – a measure still frequently used to control the spread of infection – is generally traced back to the 1300s (Tognotti, 2013), long before germs or viruses were known to cause disease. Centuries later, John Snow, seen by many as the father of the science of epidemiology, succeeded in persuading the authorities to put in place an effective ‘policy response’ – the removal of the Broad Street pump handle, which, according to the standard, although unfortunately partly apocryphal account (McLeod 2000; Paneth 2004) brought to an end a major cholera outbreak in Soho, London in 1854 – without any detailed understanding of the Vibro cholerae bacteria that cause the disease.
Over time, the germ theory of disease and many other scientific discoveries have incrementally improved societies’ ability to prevent and contain outbreaks, and to cure the sick. It is central to the approach adopted in this book, however, that even ‘technical’ public health interventions are profoundly and unavoidably political, being tightly bound up with prevailing power structures as well as societal norms, rules and institutions. Political changes, as well as breakthroughs in science and medicine, have affected the options available to policymakers seeking to respond to disease outbreaks, and the acceptability of certain kinds of interventions has varied over time.
The practice of ‘shutting up’ houses during the London plague of 1665 is one example of the ways in which public health ethics have shifted in tandem with wider social norms, in turn changing understandings of the legitimate exercise of power. Shutting up – discussed by Samuel Pepys and Daniel Defoe, amongst others (McKinlay 2009) – was carried out on houses in which a resident had died of plague. Those living in the house, even those who were asymptomatic, were forcibly confined to the premises, with the doors being padlocked and watchmen stationed outside to prevent escape, as a means of protecting the wider community against the threat of contagion. Such policies, which effectively imprisoned those guilty of no crime and involved knowingly incarcerating the healthy alongside those thought likely to be contagious, are difficult to reconcile with modern ideas of medical ethics and human rights. But even here we can find historical continuities. Just as the plague itself remains a touchstone for modern political debates, policies such as shutting up continue to provide the background to contemporary discussions of epidemic response. At the time of the 2009–10 H1N1 ‘swine flu’ outbreak, the journal Public Health Ethics reproduced an anonymous 1665 pamphlet on the ethics of shutting up (Anonymous 2010), arguing that ‘it is interesting to see that the seven arguments that are advanced against compulsory isolation [in the pamphlet] are, mostly, as relevant today as they were in 1665’ (Verweij and Dawson 2010: 1–2). The points made by the anonymous pamphleteer in the seventeenth century were indeed strikingly similar to some of those seen in contemporary debates over quarantine, including arguments focusing on the threat to human dignity (which might now be couched in terms of human rights or civil liberties), its effectiveness as a method of disease control, and the unintended consequences of such restrictive measures. Here we see the history of disease control efforts directly informing discussions which bring together medico-scientific evidence and political considerations in determining what types of policy response to disease outbreaks are and are not ethically acceptable – a key theme of subsequent chapters.
A related issue that will recur throughout the book is that medical and scientific developments do not always make us safer from disease, and even when they do, they often raise new political questions to which the answers are not always simple. Most medics and medical researchers would no doubt want to argue that the history of medicine is overwhelmingly a history of discoveries that have improved human health and wellbeing. Comparing contemporary life expectancies (especially in developed countries) or contemporary child survival statistics with those of past centuries makes the point powerfully. Yet scientific progress is not a one-way street. Some scientific developments have opened up new forms of risk – as we will see in chapter 3 with recent breakthroughs in synthetic biology that raise the possibility of new and more deadly pathogens being deliberately created. Even where the positive health benefits of scientific research have been more uncontroversial, hugely politicized questions have arisen. Amongst others, we have seen this in debates over the appropriate focus of research efforts and the distribution of the resulting benefits. The identification of a category of ‘Neglected Tropical Diseases’ (NTDs) was based on the realization that certain diseases suffer from severe underinvestment in terms of pharmaceutical research and development – particularly those diseases that primarily affect poor populations in the Global South, who represent a relatively unattractive market for private pharmaceutical firms (Hotez 2008). In some cases where new drugs have been developed, there have been lengthy struggles over their affordability, most famously seen in the activism of the late 1990s and early 2000s that sought to establish the right of poor people living with HIV and AIDS to have access to antiretroviral therapies (Chan 2015: chapter 3). The (relatively) rich and powerful – or those, such as militaries, deemed to be strategically important – have usually been the first to benefit from new medical and scientific advances. Yet, as is discussed in the next section, the poor have sometimes benefitted too. Disease has transformed the relationship between governors and governed. Indeed, protection of the population from illness, to make them healthy and productive citizens, has become integral to the very raison d'être of the modern nation state.
Disease, the Individual and the State
As someone profoundly interested in the historical development of the relationship between states and their citizens, Michel Foucault devoted considerable energy to understanding the ways in which health and medicine have impacted upon those relationships. He identified the eighteenth century as a turning point – an era that (in Western European states, at least) ‘saw the multiplication of doctors, the foundation of new hospitals, the opening of free health clinics, and, in a general fashion, an increased consumption of treatment in every class of society’ (Foucault 2014: 114). Crucially, however, Foucault traced the effects of these developments far beyond medical facilities and individual doctor–patient relationships, noting an
at least partial integration of medical practice with economic and political managements, which aimed at the rationalization of society. Medicine was no longer simply an important technique in the lives and deaths of individuals about which the collectivities were never indifferent; it became, in the framework of group decisions, an essential element for the maintenance and development of the collectivity. (Foucault 2014: 114)
For Foucault, then, medicine served an important function in establishing and strengthening collective (national) identities. Priscilla Wald (2008: 51) argues much the same thing about modern narratives of disease in which ‘The depiction of contagion offers a visceral way to imagine communal affiliation in national terms.’ The result of emerging governmental interest in health and disease within the population, according to Foucault, was a range of new government priorities around surveillance, continually measuring and collecting health data, and putting in place preventive measures – sometimes seen as paternalistic or even authoritarian interventions – to improve public health. New forms of state bureaucracy emerged to fulfil these functions.
Infectious diseases such as plague, leprosy and cholera were particularly important in this developing state role in protecting (and at the same time seeking to exert control over) populations. In part this was simply a reflection of the most pressing health challenges facing those societies at that time. For most of human history, infectious diseases have been the primary cause of premature death and serious illness. For most of the developed world this is no longer the case, with non-communicable diseases (NCDs) (sometimes popularly, but problematically, characterized as ‘lifestyle diseases’) now representing the primary disease burden in comparatively wealthier societies. US Surgeon-General William H. Stewart is remembered for having (supposedly) declared in the late 1960s that ‘It is time to close the book on infectious diseases, and declare the war against pestilence won.’ Whilst there is room for doubt about whether Stewart ever in fact said such a thing (Spellberg and Taylor-Blake 2013), the quote is taken by many to be representative of a more general feeling in the mid-twentieth century that the era of infectious diseases as a major cause of death in the developed world was over. This claim has been roundly mocked by subsequent commentators, especially given the rise of antibiotic resistance and the contemporary prominence of ‘Emerging Infectious Diseases’ (EIDs) in public health policy discourse, discussed in detail in the next chapter (see also Lakoff and Collier 2008: 9; Weir and Mykhalovskiy 2010). Yet the over-exaggeration hides a broader truth about epidemiological transition in the developed world in which infectious diseases now rank lowly in the list of routine population health threats as compared with risk factors such as obesity, smoking and the consumption of alcohol (GBD 2015 Mortality and Causes of Death Collaborators 2016). Even in the Global South, where infectious diseases still account for a relatively high percentage of the total disease burden, a notable shift is under way in which non-communicable diseases are moving up the league tables of causes of death (see chapter 6).
But the fact that infectious diseases were (and in many places still are) a major cause of sickness and death is not the sole reason for their historical prominence on government agendas. Some of the other reasons for this prioritization, indeed, are important in helping us to explain the continuing privileging of communicable over non-communicable diseases in contemporary global health governance (Youde 2012: 160). First, contagion is a process that by its very nature generates fear within populations, and consequently also within governments. The spread of a disease, especially a deadly one, through a community inevitably creates intense concern amongst citizens, media and government. Better surveillance data and improved knowledge about the transmission of diseases may make modern societies even more prone to such ‘pandemic anxiety’ (Ingram 2008). Second, the cross-border movement of pathogens adds a further dimension to this fear of contagion, invoking comparisons with a military invasion, and frequently leading to the linking of disease importation with other security concerns, including migration and border security (Coker and Ingram 2006). Third, infectious diseases often affect those who, historically, have mattered most to a state: young men who are economically productive and are needed to serve in the military. For most of history, health threats to women, such as unsafe childbirth, have, frankly, mattered little to the state. The same is true of illnesses that primarily affect the elderly. Fourth, the very fact that infectious diseases are now a less common cause of death in the developed world than non-communicable diseases seems to have brought a greater degree of sensitivity to such ‘unusual’ forms of threat, creating the sense of impending crisis seen in the public discourse over many of the cases examined in this book, from SARS to Ebola. Finally, over time there has been an increasing emphasis not only on the direct impact of disease on society in terms of illness and death, but also the spillover effects such as economic losses and societal disruption.1 In short, there are a range of persuasive reasons why governments have interpreted infectious disease threats in particular (security-laden) ways, and why they have wanted to put in place measures to provide their populations with protection.
If political and security concerns have made governments take notice of infectious diseases, they have also affected their responses. Power and ideology have profoundly shaped the ways in which governments have interpreted and addressed disease threats within and beyond their borders. To take one example, the fact that the biomedical model came to dominate health policymaking in the twentieth century has been seen as having narrowed the terms of the debate. As Priscilla Wald notes in her discussion of Laurie Garrett's seminal The Coming Plague (Garrett 1994), a book that played an important part in convincing the Clinton administration of the threat to the US posed by infectious diseases, ‘The familiar story she … summons – the outbreak narrative – shifts the terms of her analysis of global health. Microbial warfare directs attention to the microbes and thereby presents the threat of disease emergence in predominantly medical terms’ (Wald 2008: 267). As we will see in chapters 5 and 6, getting lost in such a medicalized account are the deeper structural factors that determine health outcomes – not least the scourge of poverty (Farmer 1999; Hays 2009: chapter 12). The ‘pro-health politics’ that I make a case for in the Conclusion to this book, following this line of thought, is not a narrow medico-pharmaceutical ‘war’ against microbes (or, at least, not only that), but rather one that embraces critical public health's traditional strengths of identifying and seeking to tackle the underlying political, social and economic determinants of poor health, not least national and global inequalities. Too often, as I show in the chapters that follow, the primary interest of powerful states has been in combatting individual ‘threatening’ microbes rather than grappling with the deeper structural causes of health insecurity.
The Threat of the ‘Other’ and the Need for International Responses
The twentieth century and the advent of the biomedical approach did not create this defensive dynamic de novo. Rather, biomedicine combined with pre-existing ideas about disease and insecurity and with a long history of thinking about threats posed by the ‘other’ residing beyond our borders. For centuries, fears of ‘new’ or ‘foreign’ diseases have been closely bound up with fears of other peoples – especially those seen as ‘primitive’ – and, thus, with a wider politics of race, colonization and domination. Here, too, we find continuities.
The origins of the modern discipline of global public health can be traced back to colonial-era ‘tropical medicine’ (Aginam 2003). Whilst tropical medicine was, on the face of it at least, concerned with dividing the world climatically, between the ‘tropics’ and the temperate climates of Western Europe and North America, it frequently slipped into ideas that seem jarring to modern ears, including tropes about unhygienic lifestyles and primitive cultural practices in the (colonized) tropics and the superiority of (white, Western) medical knowledge and technologies. As Alison Bashford (2004) has noted, tropical medicine became not only about health narrowly defined, but part of the prevailing ‘systems and cultures of race management’ designed to segregate the safe spaces of the colonizer from the dangerous colonized through cordons sanitaires and other public health-framed policy interventions.
It would be surprising to see such explicitly racialized ideas in contemporary global health discourse, but some are beginning to question whether contemporary global health itself is in some respects neocolonialist (Horton 2013). Certainly, as we will see in later chapters, it is possible to discern striking similarities between tropical medicine ideas of the nineteenth century and some of the underpinning assumptions detectable in discussions of (global) health security in the present day. For Obijofor Aginam (2003), attempts to ‘insulate’ Europe from the diseases of the barbarous ‘other’ remain readily discernible in contemporary global health governance in which, despite the rhetoric of shared risk in a globalized world (see chapter 5), ‘over 3.3 billion people in the world are banished to the penitentiary of health insecurity’. Along the same lines, Gregory Bankoff finds in current discussions of Western vulnerability to disease a continuation of a historical discourse which
denigrates large regions of the world as dangerous – disease-ridden, poverty-stricken and disaster-prone; one that depicts the inhabitants of these regions as inferior – untutored, incapable, victims; and that it reposes in Western medicine, investment and preventive systems the expertise required to remedy these ills. (Bankoff 2001: 29)
The earliest international efforts by governments to develop cooperative mechanisms to mitigate the risks posed by the transnational spread of disease, not coincidentally, came about during the colonial era. International cooperation on disease control is most commonly traced back to the International Sanitary Conferences of the mid-nineteenth century, which brought together European states concerned with harmonizing quarantine regulations in order to control cholera, plague and yellow fever. David Fidler (2001) identifies the 1851–1881 International Sanitary Conferences as the birth of what has now come to be known as ‘global health diplomacy’, with each of the countries taking part in the conferences being represented by a diplomat and a physician (Howard-Jones 1975: 12), an early glimpse of what has in recent years become a far more routine cooperation between the worlds of public health/medicine and foreign policy (Elbe 2010). Some of the themes identified in the preceding discussions – including scientific debates over the aetiology of cholera – were major features of these nineteenth-century conferences, with progress on international action being stymied by unreconciled differences in opinion over the cause of transmission (Hoffman 2010; Howard-Jones 1975). Whilst that uncertainty disappeared as a result of subsequent scientific advances, the historical continuities between nineteenth-century multilateral disease control efforts and those of the present day are in some ways more striking than the discontinuities.
One such continuity is the wish of governments to balance disease control with their desire to keep international trade moving. The Conferences of the nineteenth century involved the major (primarily European) maritime powers of the day, with the first International Sanitary Convention, finally agreed in 1892 at the seventh in the series of conferences, being focused on harmonizing quarantine arrangements for ships passing through the Suez Canal. The gradual institutionalization of these international arrangements (Hoffman 2010) led ultimately to the adoption of the International Sanitary Regulations by the new WHO in 1951 (WHA 1951
