Biosecurity and the Risk to Global Health
Abstract and Keywords
Global health is potentially diminished by practices of biosecurity aimed at safeguarding the health of human populations against selected infectious disease risks. Some diseases inspire so much government concern that they are accorded the status of security issues, and adopting a security-based rationale for prevention and response efforts can garner extra resources and stronger powers for risk-reduction purposes. However, such an approach can result in practices that are counterproductive from a health perspective. This chapter shows that biosecurity can endanger global health in at least four areas of policy concern: the development of defences against biological weapons, the management of security risks arising from laboratory research on pathogenic microorganisms, the prioritization of disease risks and response mechanisms as part of an agenda of global health security, and the use of national borders to contain transnational contagion.
A myriad of allergies, congenital conditions, physical injuries, mental health disorders, occupational illnesses, and cancers afflict millions of people worldwide. In addition, there are hundreds of types of microorganism (viruses, bacteria, etc.) that infect and sicken humans on a huge scale, especially in poorer parts of the world. These latter, the infectious diseases, many of them contagious, tend to attract a higher degree of public concern and political attention than do the former. Moreover, although diseases lacking a microbial cause are a serious health burden in many places, the sudden outbreak of a deadly infectious disease has a greater capacity to excite the attention of policymakers. In developed countries especially, where populations are less accustomed to infectious disease posing a deadly risk, fear of these diseases is attributable to a combination of factors beyond simply the number of cases or deaths experienced or expected in an outbreak. These factors include a disease’s historical reputation, its gruesome symptoms, the unavailability of effective medical treatment, and the past or potential use of a disease in a biological attack. This last is a particularly powerful factor that compounds people’s visceral fear of involuntary exposure to an unfamiliar and invisible (microscopic) risk, because it seems worse to be deliberately and maliciously infected.
Some infectious diseases inspire so much public anxiety and government concern that they are accorded the status of security issues. However, adopting a security-oriented approach to preventing or responding to disease outbreaks is not necessarily a wise move, because security (as a political practice) is not necessarily a good thing. Historically, appealing to security has resulted in many a vital project being funded but also in much money being wasted. Raising security concerns can be a device for maintaining secrecy as well as for increasing public awareness, and a determination to pursue security can result in the perpetration of injustices as well as the achievement of admirable goals. This chapter seeks to show that a particular kind of security practice—biosecurity—potentially diminishes global health. Biosecurity practices are defined here as government practices aimed at safeguarding the health of human populations within (p. 180) or across state boundaries against selected infectious disease risks. In the face of such risks, a government’s choice to ‘play the security card’ (Elbe 2011) can often garner extra resources and stronger powers for risk-reduction purposes. Yet such an approach to disease control can sometimes result in protective practices that are counterproductive from a health perspective.
The sections that follow show that biosecurity can endanger global health in at least four areas of policy concern: the development of defenses against biological weapons, the management of security risks arising from laboratory research on pathogenic microorganisms, the prioritization of disease risks and response mechanisms as part of an agenda of global health security, and the use of national borders to contain transnational contagion. Other authors have adopted a similarly broad conception of biosecurity, according to which the natural occurrence of deadly disease outbreaks is considered alongside the deliberate dissemination of pathogenic microorganisms (Collier and Lakoff 2008; Fidler and Gostin 2008). The advantage of doing this, as Gregory Koblentz (2010, 108) has argued, is that it helps ‘make explicit what would otherwise be implicit trade-offs that reduce the risk of one type of biological threat while increasing the risk of another’. In situations that seem to demand the protective effect of a particular biosecurity practice, the risk from a health perspective is that such a practice will be more harmful than beneficial. Thus the ongoing challenge for governments individually and collectively is to practice biosecurity in ways that promote rather than undermine global health.
Biosecurity as Biodefense: A Security Dilemma
Global health is potentially diminished by any increase in the overall likelihood of biological attacks occurring somewhere in the world. State-based efforts to defend against biological attacks (biodefense) do not, for the most part, present a problem in this regard. For example, accumulating medical supplies and upgrading hospitals’ capacity to treat attack victims are generally not regarded by other states as worrisome activities. However, an international political problem might arise when a government undertakes biodefense activities for ‘threat assessment’ purposes, and here the essential problem is one of offense/defense differentiation. One state’s activities, purportedly aimed at affording protection against pathogenic microorganisms that are deliberately disseminated, might be perceived by the government of another state as having an offensive purpose. And if that suspicion occasioned similar activities (investigations into offensive capabilities) to occur in that other state, the result could be a proliferation of biological weapons and an increasing likelihood of biological attacks as each side continued to compete for technological advantage.
One state’s possession of particular technologies, or its conduct of particular activities, might not in fact be intended to threaten another state. But when such a fact is difficult (p. 181) to verify, a state that is uncertain of another’s capabilities and intentions is liable to assume the worst and act to bolster its own security. The effect that this security-seeking behavior has on other states—increased concern for their own security—is conceivably unnecessary, and it is counterproductive if it causes those other states to act in ways that confirm or compound prior fears. This predicament of wanting to improve one’s security circumstances but running the risk of achieving the opposite is known more generally in international relations as the security dilemma (Booth and Wheeler 2008). The international suspicion that lies at the heart of the dilemma can sometimes be reduced by material considerations. For example, military capabilities that are geared toward offense are generally regarded as more fearsome than capabilities that are plausibly defensive in nature. So when defensive weapons are clearly different from offensive weapons, it is possible for a state to acquire or accumulate the former without making other states feel less secure (Jervis 1978, 187). In other circumstances and in respect of other capabilities, however, a state might judge that an offense/defense distinction cannot plausibly and safely be drawn. The need to act out of fear would then continue to be felt, and so the security dilemma would remain. In the case of intercontinental ballistic missiles bearing nuclear warheads, for example, there is deep uncertainty about an offensive capability that is supposedly defensive; a state’s defense relies on deterring nuclear-armed enemies from attacking it by threatening a nuclear attack as punishment. Here, it is the status of these weapons as ‘inherently ambiguous symbols’ that materially establishes the security dilemma (Booth and Wheeler 2008, 1).
Ambiguity can also be fearsome and dangerous when it comes to biological weapons. One way in which the process of wielding a biological weapon works is as follows: a pathogenic microorganism is chosen, then produced in large quantities through a fermentation process, inserted into a dispersal mechanism, and disseminated in such a way that it survives meteorological conditions on its way to infecting and sickening human targets. The closer a state is to being able to carry out such a process, the closer it is to being in a position to threaten other states. That state could claim that it has placed itself in that position only for the purpose of fully understanding the nature of the threat it faces or might face from other states. However, the problem with experimenting with offensive applications of biotechnology, and with claiming that doing so serves a defensive purpose, is that this puts the offense/defense distinction under great pressure. If all that separates a biodefense program from a biological weapons program is the operator’s intent, other states might be disposed to prepare for a rival’s sudden change of mind by investigating the offensive capabilities they fear; whereas capabilities take time to develop, intentions can change overnight. Security dilemmas in combination could then lead to a security paradox: more offensive know-how all around and more danger of biological attacks against more states. For this reason, it is important for a national government to be sensitive to how its own biodefense activities may be perceived.
Of particular concern are certain biodefense activities conducted by the US military for threat assessment purposes which, were they conducted by a rival state, would almost certainly attract US condemnation. A government’s investigation of mechanisms for dispersing pathogenic microorganisms in a particular way and over a wide area can (p. 182) serve a genuine defensive purpose, such as informing the design or improvement of protective bodysuits and devices for detecting airborne microorganisms. It is also the case, however, that such investigation could guide the planning and execution of a biological attack. As noted in a 1998 US government report: ‘Stabilization and dispersion [research] are proliferation concerns because these technologies increase the efficacy of biological [warfare] agents’ (US Department of Defense 1998). At around the time this report was written, the US government was conducting a number of secret biodefense experiments of a kind that, after their revelation by the New York Times in 2001, raised questions about whether they were geared more toward offense than defense. From 1997 to 2000, for example, Project Clear Vision (sponsored by the Central Intelligence Agency) involved the building and testing of a Soviet-model ‘bomblet’ for dispersing bacteria (Miller et al. 2001a). A number of these bomblets were reportedly filled with simulant pathogens (unable to cause disease) and tested for their dissemination characteristics and reliability under various atmospheric conditions. Experiments in a wind tunnel revealed how the bomblets would fall on targets after being released from a warhead (Miller et al. 2001b, 295). From the perspective of an outside observer, was this an instance of US biodefense activities bringing the ‘biological’ overly close to the ‘weapon’?
More recently, biodefense research carried out by the US Army has included the use of various uncontained spaces to explore possibilities for dispersal of biological material. For example, among the ‘tunnel dissemination systems’ at the army’s Dugway Proving Ground in Utah, the Joint Ambient Breeze Tunnel features an ‘overhead, four-zone Sono-Tek nozzle array’, with maneuverable dissemination carts providing for ‘precision set-up of aerosol cloud generation’ (US Army 2012, 44). Here, ‘[p]ortable liquid and dry dissemination systems may be operated for specific tests to replicate an attack (e.g., covert backpack attack), including electric Micronair sprayers and E2 sprayers, Skil® blowers, and puff disseminators’ (US Army 2012, 44). And when a Skil® blower is used to release ‘5 to 10 grams’ of a ‘dry powder simulant’, it creates ‘a concentration of 5,000 to 20,000 particles per liter inside a tunnel’ (US Army 2012, 44). Biodefense work at Dugway’s Lothar Salomon Test Facility includes the use of ‘simulants’ in ‘outdoor studies’ to ‘develop/validate aerosol particle dispersion models to enhance countermeasure response’ (United States of America 2016, 42). For example, simulants used in a 2005 field trial of the Joint Biological Standoff Detection System included a ‘[d]ry killed vaccine strain of Bacillus anthracis [anthrax]’ and a ‘[w]et killed vaccine strain … of Yersinia pestis [plague]’ (Buteau et al. 2007, 11). The trial included one late-night dissemination of 20 grams of dry anthrax simulant at a ‘target range’ of 1.2 km and another at a range of 2.6 km, and disseminations of 3.5 liters and 7.0 liters of plague simulant at a target range of 1.2 km and 7.0 km, respectively (Buteau et al. 2007, 37–40).
The latter form of experimentation is presumably driven by two assumptions: first, that the systems being tested would be able to detect the dispersal of living bacteria as well as dead ones; and second, that the dispersal mechanisms used to challenge those systems would deliver both kinds of material to the target in the same way. It follows that the operator of the dispersal mechanisms would only need to fill them with real pathogens (p. 183) to be in a position to perpetrate a real biological attack. For this very reason, though, the US government would probably take a dim view of similar dispersal capabilities in the hands of a foreign government. Yet if the security dilemma argument presented here holds true, it is also possible that any investigations by other states into offense-capable technology are being driven (at least in part) by a concern to anticipate a US biological attack. From the perspective of global health, this possibility is worrying. With multiple states competing to maintain a technological edge and thus endowing themselves with offensive know-how, the paradoxical consequence of this protective effort might be an increased risk that someone somewhere in the world will be attacked with a biological weapon. Biosecurity in the form of biodefense should not be more trouble than it is worth, so governments mindful of the security dilemma would be wise to avoid experimenting with delivery systems that replicate biological attacks.
Biosecurity as Information Security: Censoring the Findings of Pathogen Research
A large-scale biodefense enterprise, even if it is primarily directed toward defending against biological attacks, can also protect human health against infectious disease risks more generally. Government-sponsored laboratory research can lead to vital scientific discoveries about the behavior and properties of pathogenic microorganisms, and the consequent development of pharmaceutical countermeasures (vaccines, antibiotics, etc.) undoubtedly benefits the people who are able to receive them when needed. Nevertheless, it is also the case that laboratory-based pathogen research can itself pose risks to public health, so another form of biosecurity practice is the regulation of scientists’ activities. Unsafe working environments can result in accidental infections and the escape of a dangerous pathogen from a laboratory. Another possibility is that a scientist could steal and maliciously use a pathogen to cause harm. Imposing regulations on scientific conduct protects human health to the extent that this makes such incidents less likely, but the countervailing risk is that a government might thereby end up stifling researchers’ pursuit of discoveries that could one day lead to the saving of many lives.
The conundrum, then, is that the securing of populations against selected infectious disease risks can seem to require both the restricting and the facilitating of research efforts. Such efforts include the communication to other scientists (through publication in scientific journals) of information on how experiments involving pathogenic microorganisms were conducted and the results of those experiments. In addition, when a particular experiment results in the creation of a microorganism that is more dangerous to humans (more transmissible, more virulent, etc.), doubts might arise about whether the benefits of publication outweigh the risks. On the one hand, it might be argued that the mass communication of information on how a pathogen can become (and be made) (p. 184) more dangerous could enable and encourage the use of that information for a harmful purpose (such as a biological attack). On the other hand, making such findings widely available to other scientists might vitally assist the development of new or improved measures for controlling the relevant infectious disease. To the extent that sharing research findings with other scientists would be beneficial to public health, there is a technology-transfer imperative. But if there are risks associated with such sharing, a government might also act upon a perceived non-proliferation imperative to prevent this.
The dilemma is well illustrated by the controversy surrounding the publication in 2012 of certain findings from research into the potential of H5N1 avian influenza (bird flu) to become more transmissible (Herfst et al. 2012). At the time of writing, there had been 860 confirmed human cases of H5N1 avian influenza in sixteen countries since 2003, including 454 deaths (a global average case-fatality rate of around 53 percent) (World Health Organization 2017). The continued circulation of H5N1 in poultry, and occasional infections of humans, has enabled ongoing viral evolution, and a key question for scientists has been whether this could eventually lead to the emergence among the human population of a virus with pandemic potential. Such a virus would be able to spread through the air between humans, and it would present a serious danger to public health globally, so some influenza researchers have been interested to discover which genetic mutations might allow H5N1 to do this. Ron Fouchier at the Erasmus Medical Centre (EMC) in Rotterdam, the Netherlands, was one of many scientists funded by the US National Institutes of Health to conduct experiments to investigate how H5N1 might evolve to acquire the ability to spread from person to person (Maher 2012, 432). In September 2011 Fouchier announced a breakthrough: using genetic engineering techniques, he and his research team had succeeded in causing the mutation of H5N1 into a form directly transmissible (through the air) between animals (Specter 2011). A ferret’s respiratory system closely resembles that of a human, and ferret-to-ferret transmission of influenza virus is generally assumed to demonstrate human-to-human transmissibility. Thus it seemed that a new and presumably pandemic virus had emerged not through natural evolutionary processes, but rather as a result of human experimentation.
A written account of this discovery (including a description of how it was achieved) was made ready for submission to the highly respected US-based journal Science. Soon afterward, however, the Dutch government took an extraordinary action, requiring Fouchier to apply for and be granted permission to ‘export’ his team’s research findings beyond the European Union (EU) (Enserink 2012a). The legal basis for this intervention was EU Council Regulation 428/2009, which provides a framework for EU states to control exports of dual-use technology to non-EU states (European Union 2009). On April 27, 2012, the Dutch minister for agriculture and foreign trade announced his decision to allow the export of H5N1 technology to the editor of Science in this instance, stating that he had ‘weighed all of the benefits and risks of publication of the avian influenza research’ (Enserink 2012b). It is not clear exactly how the Dutch government arrived at and justified its decision. Did it do the right thing in allowing publication to (p. 185) proceed? Or should it instead have withheld an export permit and effectively censored Fouchier’s research findings?
From a global health perspective, censorship might have been a beneficial move, insofar as it would have reduced the likelihood of Fouchier’s H5N1 experiment technique being applied by other scientists. Even if it was sufficiently safe for Fouchier and his colleagues to conduct their experiment inside the EMC in Rotterdam, the same work done (using a published methodology) in less well-managed laboratories elsewhere in the world might carry a greater risk of unintentional release of the mutated H5N1 virus. According to one estimate, the likelihood of a scientist somewhere being infected accidentally approaches 20 percent over a ten-year period (Lipsitch and Galvani 2014). Although Fouchier has insisted that ‘scientific research has never triggered a virus pandemic’ (Sample 2014), accidental infections involving the contagious severe acute respiratory syndrome (SARS) virus have gone undetected before (Murphy 2004; Yardley and Altman 2004). In addition, there is a risk that publishing a technique for producing a more dangerous version of H5N1 increases the likelihood of such technology being applied for a harmful purpose. The justification for censorship, then, might be, as Michael Osterholm has put it: ‘We don’t want to give bad guys a road map on how to make bad bugs really bad’ (Enserink 2011).
On the other hand, if Fouchier’s H5N1 research findings had been censored, this could have been bad for global health for at least two reasons. First, censorship might have inhibited the ability of scientists (as readers of Science) to use a new discovery to better prepare for a pandemic. Several influenza virologists have emphasized the importance of information sharing for disease surveillance and vaccine-testing purposes (Osterhaus 2012; Palese and Wang 2012), and Fouchier’s core argument at the time was:
We have to be prepared for such viruses to emerge in the wild. If we would detect these viruses out in the field, then we could go out to outbreak areas and try to eradicate the virus and prevent a pandemic from happening. If that would fail, then we would still be in a good position to, ahead of that pandemic, evaluate our vaccines and anti-viral drugs and therefore gain months of time if a pandemic would hit and therefore we would be able to handle it better.
A second reason that censorship might have been bad for global health is that concealment of information by one government can sometimes undermine international trust and cooperation. To the extent that preventing publication of Fouchier’s H5N1 findings would have limited access to potential public health benefits, the governments of developing countries in particular could have characterized this as contrary to the spirit of the 2011 Pandemic Influenza Preparedness Framework [PIPF] for the Sharing of Influenza Viruses and Access to Vaccines and Other Benefits (World Health Organization 2011b). This is an international agreement to share influenza virus samples and related information, and it critically relies on confidence that low-income countries (from which most H5N1 samples are sourced) will benefit from influenza research carried out in high-income countries. However, as the next section shows, such confidence can be undermined (p. 186) by perceptions that useful (albeit dual-use) technology and associated benefits are being deliberately withheld. The consequence thereof might be a downgrading of international cooperation on disease surveillance and influenza vaccine development, to the overall detriment of global health.
Biosecurity as Global Health Security: Prioritizing Risks and Responses
Beyond biodefense and censorship carried out by governments individually, biosecurity can also be a cooperative practice engaged in by multiple governments for the sake of populations that are collectively vulnerable to infectious diseases. Here too, difficulties can arise when priority status for a narrow range of disease risks (including the risk of biological attacks) is institutionalized by international health-governance arrangements for ‘global health security’. The challenge is to achieve extra protection for populations worldwide against prioritized disease risks without thereby neglecting other serious health burdens and health system problems in particular parts of the world. At the heart of this challenge is the tension between prioritization policies that promise to satisfy the greatest quantum of human need and those that are most likely to be politically feasible. David Stuckler and Martin McKee (2008) have observed that policymakers use different metaphors for global health, each of which results in the term meaning something other than the perfect health and complete well-being of all people everywhere. In accordance with the metaphor of ‘global health as public health’, for example, attention and resources are directed toward ‘decreas[ing] the worldwide burden of disease, with priority given to those risk factors and diseases that make the greatest contribution to this burden’ (96). This may be contrasted with the ‘global health as security’ metaphor, according to which health policy seeks to ‘protect one’s own [national] population, focusing mainly on communicable diseases that threaten this population’ (Stuckler and McKee 2008, 96). Emphasizing some infectious disease risks in pursuit of an agenda of global health security seems more likely to attract political and financial commitments from wealthy governments that are fearful of those diseases. However, such an arrangement could generate less public health benefit throughout the world than would one whose broader humanitarian rationale might be politically more difficult to support over the long term.
In 2007 a World Health Organization (WHO) report defined ‘global public health security’ as ‘the activities required, both proactive and reactive, to minimize vulnerability to acute public health events that endanger the collective health of populations living across geographical regions and international boundaries’ (5). This definition immediately brings to mind outbreaks of diseases that are both deadly and fast spreading, like SARS and pandemic influenza. The implication of such framing is that problems of a non-‘acute’ nature are excluded from the agenda of global health security, even though the sum of such problems accounts for the greater part of health need throughout the (p. 187) world. For this reason, the institutionalized privileging of certain disease risks with conferred security status has been much criticized. In academic literature on the linking of health and security, a common complaint is that high-profile infectious diseases receive too much attention and that other health burdens (as reflected in morbidity and mortality statistics) are neglected. For example, Colleen O’Manique (2012, 167) has claimed that ‘[t]oday’s health and security agenda ignores … the boring, persistent, communicable and non-communicable diseases that in fact kill more people annually worldwide than high-profile diseases’. Simon Rushton (2011,: 780) has observed that global health security is in practice focused on ‘the protection of the West from threats emanating from the developing world’. And Debra DeLaet (2015, 342) has argued that placing diseases on security agendas is driven by ‘the political interests, strategic calculations, and influence of key actors in global health rather than … an objective assessment of where the most critical health needs exist’.
The suggestion seems to be that more lives would be saved, and a greater quantum of health need fulfilled, if political attention were diverted away from diseases deemed to be of security concern and toward those health risks that are presently ‘the big killers’. One argument against this is that it is not enough to assemble health statistics demonstrating the actual burden of various disease risks and at any given moment contrast this with the non-occurrence of, say, an Ebola outbreak. This is because any priority-setting based solely on that assessment would fail to account for the possibility that the future might differ from the present. From the perspective of governments in developing countries, preparing for future ‘acute public health events’ (World Health Organization 2007, 5) might indeed appear, in the present, to entail the relative neglect of serious health burdens of an ongoing nature. However, poorer populations are generally more vulnerable to the effects of transnational epidemics when they eventually occur. Thus, even if the level of concern in developed countries about the spread of deadly infectious diseases seems excessive at times, it could be argued that governments in the developing world have a long-term interest in playing along.
The agenda of global health security, institutionalized through the revised International Health Regulations (IHRs) of 2005, emphasizes local and global surveillance to detect deadly and contagious infectious disease outbreaks, and it calls for rapid responses to any ‘public health emergency of international concern’ (World Health Organization 2008). The IHRs place states under a legal obligation to report these types of outbreaks to WHO within twenty-four hours and to maintain their own core capacities for disease surveillance and rapid response. The idea is that with highly sensitive and well-connected surveillance systems in place, disease outbreaks will be detected and contained rapidly wherever in the world they occur. Of particular concern in this regard is the need to respond quickly to an emergent influenza pandemic which, if severe, could cause illness and death on a large scale, over a wide area, in a short space of time. Under the IHRs, the emergence of a new subtype of human influenza is automatically notifiable to WHO, which a decade ago described pandemic influenza as ‘the most feared security threat’ (World Health Organization 2007, 45).
(p. 188) The principal benefit to be derived from global surveillance of influenza viruses is an early warning to all governments of the emergence, anywhere in the world, of a virus with pandemic properties. Such a warning of the commencement of human-to-human viral transmission is valuable because it supposedly allows everyone more time to, if possible, organize and implement a response. However, the value of a warning is potentially diminished by the continued inability of many countries to secure an adequate supply of pandemic influenza vaccines. A fundamental and persistent problem is that the total amount of influenza vaccine that can be produced annually is far from enough to protect everyone everywhere. The availability of a pandemic vaccine is not truly global, despite pandemic influenza having acquired priority status as a disease that poses a global health security risk. Therefore, only the wealthiest of countries, whose governments have pre-ordered doses of vaccine, are able to take full advantage of global influenza surveillance as a biosecurity practice. In mid-2009, for example, the United States had already ordered 40 million doses of vaccine against the pandemic H1N1 swine flu virus; the United Kingdom had ordered 90 million and France 50 million (Hayden 2009). Six months into that pandemic, only 534 million doses were available worldwide, and after one year there were 1.3 billion (Stöhr 2014). And so for the duration of the pandemic, a large majority of the world’s population (including many in countries with high incidence of infection) remained unprotected by vaccination.
That swine flu pandemic turned out to be a mild one, but concerns about vaccine availability had been raised earlier by the governments of some developing countries fearful of the pandemic potential of H5N1 bird flu. In January 2007 the Indonesian government drew attention to its concerns by abruptly withholding samples of H5N1 virus from the WHO Global Influenza Surveillance Network. At that time Indonesia was continuing to experience many more cases of human H5N1 infection than any other country. Therefore Indonesia was a vital source of information on that influenza virus’s properties and whether it might be mutating into a pandemic form. Indonesia’s health minister, Siti Supari, used this fact to apply political pressure to further her country’s health interests. At a meeting with WHO officials in March 2007, she sought assurances that Indonesia would receive vaccines if a pandemic occurred, and she described the global vaccine supply scheme then in place as ‘more dangerous than the threat of an H5N1 pandemic itself’ (Normile 2007). Assistant director-general David Heymann of WHO accused Indonesia of ‘putting the public health security of the whole world at risk’ by not sharing influenza virus surveillance data (Roos 2007). However, what Indonesia was essentially claiming was that poorer countries were already experiencing a high degree of health insecurity, and that cooperation with influenza researchers worldwide seemed pointless if those countries were unable to benefit from the vaccines that result from that cooperation. This claim thus presented a fundamental challenge to the practice of biosecurity qua global health security; achieving protection against selected infectious disease risks would only happen if there was international cooperation on disease surveillance.
In formal recognition of the concern represented by Indonesia’s drastic action, four years later the World Health Assembly adopted the Pandemic Influenza Preparedness (p. 189) Framework (PIPF), which includes acknowledgements that ‘the benefits arising from the sharing of H5N1 and other influenza viruses with human pandemic potential should be shared’, and that ‘global influenza vaccine production capacity remains insufficient to meet anticipated need in a pandemic’ (World Health Organization 2011a, 3–4). Nevertheless, the PIPF is legally non-binding—offering merely an encouragement to act—in contrast to the IHRs, which institutionalize the agenda of global health security. For example, the PIPF provides that ‘[WHO] Member States should urge vaccine manufacturers to set aside a portion of each production cycle of pandemic influenza vaccine for use by developing countries’ (World Health Organization 2011a, 20; emphasis added). Therefore, despite increasing the degree of political attention given to the issue of global pandemic influenza vaccine supplies, the PIPF could be characterized as a weak instrument that diverts this issue to the sidelines of the global health security agenda. If it is, and if the governments of some countries perceive a continuing gap between disease surveillance expectations and public health benefits, the potential for another virus-sharing dispute remains as a challenge to this form of biosecurity practice.
Biosecurity as Border Security: Transnational Contagion and Travel Restrictions
The previous section discussed an international-level approach to biosecurity that is (or ought to be) inclusive and cooperative. This can be contrasted with the exclusionary and potentially divisive issue of border-based biosecurity. And yet it is also possible that the global health security agenda and restrictions on international travel (for purposes of disease control) are two sides of the same biosecurity coin. It is worth recalling that ‘global health’, as a discipline of medical science, is the sociotechnical descendent of what was previously called ‘imperial’ or ‘tropical’ medicine (Pinto et al. 2013, 12). The latter label alluded to security in the sense that in Europe in the nineteenth century, referring to parts of the world as ‘the tropics’ was ‘a way for imperial powers to define something culturally alien to, environmentally distinct from, and even threatening to Europe and other temperate regions’ (Birn 2012, 43). In accordance with this view, Scott Watson (2011, 163) has observed that the discourse and practice of ‘tropical’ medicine effectively ‘defined large portions of the earth as zones of danger for Europeans’. Between zones of danger and zones of safety, there is notionally a dividing line (border) that can be drawn and then policed as a way of protecting the health of a population on one side of the line from exposure to the diseased bodies of populations on the other side. Borders between states have long been sites of exclusionary modes of security practice. For governments confronting risks of many kinds, there is a strong and understandable temptation to think first about the territories for which they are responsible. When it (p. 190) comes to infectious diseases, and because human bodies can harbor disease-causing microorganisms, resisting a deadly and fearsome contagion can sometimes seem to require keeping people out. Border-based, migration-related biosecurity measures can thus serve a useful domestic political purpose in assuaging the anxiety of populations inside a given territory. However, preventing inward (and outward) travel is a measure that potentially does more harm than good, especially if an effective response to a disease outbreak is critically dependent on the free flow of people across international borders.
A key principle since the international health-governance arrangements of the nineteenth century, which is repeated in the contemporary IHRs, is that states responding to the spread of disease must ‘avoid unnecessary interference with international traffic and trade’ (World Health Organization 2008, 10). The rationale for this is that excessively severe restrictions on cross-border travel can exacerbate rather than mitigate the adverse impact of a transnational disease outbreak. Moreover, in today’s highly interconnected world, in which microorganisms are as mobile as their human hosts, it is widely acknowledged that the policing of borders to prevent microbial incursions is often futile. Even so, circumstances may arise in which pharmaceutical resources (antibiotics, vaccines, etc.) are unavailable or insufficient. In these cases, a conscientious government might decide that there is no alternative but to adopt the centuries-old, non-pharmaceutical approach of containing contagion by limiting human movement and interaction (‘social distancing’). This was the case when, in 2014, the governments of Guinea, Liberia, and Sierra Leone confronted the largest-ever outbreak of Ebola, a disease that could not at the time be prevented or treated by any drug. The governments of some other countries, within and beyond West Africa, responded by unilaterally banning travel to and from the outbreak zone, hoping that extreme exclusion would prevent further contagion.
This biosecurity practice, however, turned out to be counterproductive to defeating the Ebola outbreak. The Ebola virus does not transmit easily, so it is relatively easy to contain using basic infection-control measures. Therefore, in the absence of a safe and effective vaccine or therapeutic drug, the best approach to Ebola relief in West Africa was to insert a large number of capable, adequately supplied medical personnel into the situation to treat illness and prevent infection. To that end, in late July 2014 WHO director-general Margaret Chan announced a $US100 million plan to send more medical experts and supplies to the region (Nossiter and Grady 2014). Such an approach was stymied, however, by unilateral decisions by some governments to restrict or prohibit travel to and from the worst-affected countries.
On August 8, 2014, when WHO declared the Ebola outbreak to be a ‘public health emergency of international concern’, its advice to all states was: ‘There should be no general ban on international travel’ (World Health Organization 2014a). By this time, however, a number of countries were attempting to establish international border-based obstacles to the spread of Ebola. Nigeria, Kenya, Ivory Coast, and Senegal banned all travel to and from Guinea, Liberia, and Sierra Leone (Anonymous 2014a; Anonymous 2014b; AFP 2014). Air France suspended flights to Sierra Leone on the recommendation (p. 191) of the French government (Wall 2014), and the South African government announced that non-citizens arriving from Ebola-affected areas of West Africa would not be allowed into South Africa (Anonymous 2014c). The reasoning behind imposing travel bans appeared to be that if some people traveling from West Africa might be carrying the Ebola virus, preventing inward travel by all such people would reduce the Ebola importation risk to zero. However, there was no scientific basis for adopting this extremely risk-averse approach, and this is why WHO repeatedly advised against travel bans (World Health Organization 2014b). When they were implemented anyway, such bans amounted to interference with international traffic that was not only unnecessary but also counterproductive.
Travel restrictions made it more difficult to insert medical personnel and supplies into Ebola-affected countries, increasing the risk that local people would try to leave those countries in search of safety and/or treatment. In turn, this increased the risk of the disease spreading to other countries ill-equipped to cope with Ebola (Nuzzo et al. 2014, 307). By the end of August 2014, the presidents of Guinea, Liberia, and Sierra Leone were pleading for international travel bans to be lifted. In a letter to the United Nations (UN) secretary-general, the three presidents complained that the bans would end up aggravating the adverse economic effect of the Ebola outbreak and stifle attempts to control it (United Nations Security Council 2014a). The response by the UN Security Council on September 18, 2014, was to pass Resolution 2177, in which it expressed concern about ‘the detrimental effect of the isolation of the affected countries as a result of trade and travel restrictions’ (United Nations Security Council 2014b). Accordingly, the Security Council called on all states ‘to lift general travel and border restrictions’ and ‘to facilitate the delivery of assistance, including qualified, specialized and trained personnel and supplies, in response to the Ebola outbreak to the affected countries’ (United Nations Security Council 2014b). For the sake of public health within and beyond West Africa, the Security Council had moved to counteract the effect of a counterproductive, border-based biosecurity practice.
Deadly infectious disease outbreaks are a great and growing concern for governments worldwide, but particular processes of addressing disease risks are potentially bad for global health. This potential derives from various biosecurity practices that could, paradoxically, increase the risk of disease outbreaks, prevent the use of technology for life-saving purposes, neglect ongoing health system problems, or inhibit the effective containment of transnational contagion. When biosecurity is pursued in the form of biodefense, there is potential for some activities carried out for threat assessment purposes to be construed as offensive in nature. If uncertainty about one state’s experimentation with biological dispersal systems prompts other states to seek a similar capability, the result could be a dangerous spiral of suspicion, proliferation, and a greater overall risk of (p. 192) biological attacks. When biosecurity means information security, a decision to prevent the publication of pathogen research findings might reduce the risk of technology being used for a hostile purpose. However, censorship might also inhibit the exploitation of a scientific discovery for the betterment of public health. Moreover, if security-based restrictions on communication of research data are perceived as a failure to share technology with countries that need it, this could jeopardize the international cooperation necessary for research-based disease surveillance. Detecting and controlling outbreaks of deadly and contagious diseases are the primary goals when biosecurity involves pursuing a global health security agenda in cooperation with other governments. The political challenge here, though, is to ensure that the task of alleviating ongoing health system problems in the developing world, such as inadequate access to pandemic influenza vaccines, is not neglected. In circumstances in which vaccines and other pharmaceutical resources are unavailable, some governments confronting the international spread of disease will be tempted to equate biosecurity with border security. Such an approach was taken to the extreme when Ebola struck West Africa in 2014, and it may have seemed at first to be better than allowing freedom of international movement to continue in the face of contagion. But this form of biosecurity practice is wasteful if it is unnecessary, and it is harmful to global health if it inhibits a cooperative international response.
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