August 2013, No. 2 Vol. L, Security
Pandemics are for the most part disease outbreaks that become widespread as a result of the spread of human-to-human infection.1 Beyond the debilitating, sometimes fatal, consequences for those directly affected, pandemics have a range of negative social, economic and political consequences. These tend to be greater where the pandemic is a novel pathogen, has a high mortality and/or hospitalization rate and is easily spread. According to Lee Jong-wook, former Director-General of the World Health Organization (WHO), pandemics do not respect international borders.2 Therefore, they have the potential to weaken many societies, political systems and economies simultaneously.
The association of pandemics with national security threat grew to prominence in the1990s. In 1995, the World Health Assembly (WHA) agreed to revise the International Health Regulations (IHR), the only international legal framework governing how WHO and its member States should respond to infectious disease outbreaks, on the grounds that revision was needed to take “effective account of the threat posed by the international spread of new and re-emerging diseases”.3 In 2005, the IHR revisions were adopted as WHA Resolution 58.3.4 Article 2 announced that the scope and purpose of the instrument was “to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks”.5 Since its entry into force in 2007, signatory States have been working, individually and collectively, to meet their core capacity requirements under the new framework.
The focus of IHR is on the prevention and containment of public health emergencies of international concern. Member States committed themselves to building core capacities in the areas of national legislation, policy and financing, coordination and National Focal Point (NFP) communications, surveillance, response, preparedness, risk communication, and human resources and laboratories. It was widely presumed that not all member States would achieve these eight capacities by the 1 July 2012 deadline, but those that could not would identify areas in which they needed assistance in order to achieve these capacities.
The political logic behind the attachment of health to security within the IHR framework would underline their importance and help sustain the political will needed to achieve the core capacities. The global threat posed by pandemics required a global approach to security as the rapid transmission of disease in a globalized world means that capacity failures in any member State could place any other state or society in peril. By 2013, 110 member States out of 195 signatories requested an additional two-year extension to build the capacities. This unexpectedly large number could be interpreted in one of two ways. First, that member States are not taking their commitment seriously and that the use of security language in the health field is no more than rhetoric. Second, that most states face immense challenges when it comes to building core capacities, especially when domestic health systems are fragmented, inadequately funded and understaffed.
At this stage, indications point to the latter rather than former explanation. Multiple extensions were built into the IHR framework in recognition of the fact that the revised framework demanded much more of member States in terms of pandemic prevention and containment. The evident difficulties in these 110 States are largely rooted in more general health system deficiencies and do not reflect political objections to the IHR or the sense of shared responsibility for the prevention of pandemics.6
This is reflected in the fact that it is those capacities most associated with the general performance of health systems that have proven most resistant to strengthening. According to the latest figures, nearly two thirds of the States parties that reported their IHR implementation progress performed best in surveillance (with a global average score of 81 per cent), response (78 per cent), and zoonotic events (80 per cent), while performance was much lower in relation to human resources (with a global average of 53 per cent), chemical events (51 per cent) and radiological events (53 per cent).7 Some 194 member States have appointed NFPs. Assessments of NFP functionality have revealed that they “recognize the value of engaging with government sectors outside the health ministry, [but] they lack the convening power needed to establish solid and reliable linkages”.8 In other words, the NFP’s recognition of the need to engage with others may outstrip the political process. At this stage, it may be safely said that the implementation lag does not reflect a lack of commitment to IHR but lies in deeper issues surrounding state capacity and political processes. In these circumstances, viewing pandemics as a security issue has encouraged a deepening of commitment to international cooperation and pandemic preparedness, but some of the associated structural changes will take more time.
One response to the capacity challenge has been the promotion of a more targeted approach to implementation. In 2013, Margaret Chan, Director-General of WHO argued: “The aim [of IHR core capacities] is not only to achieve the widest possible population coverage. It is also to ensure that there are no significant gaps at the national level, as these have the potential to threaten the health security of all countries in the world”.9 There are two interrelated concepts in her statement: the responsibility of states to protect as many of their citizens as possible and their responsibility to health security between states. The relationship between individual, national and international security is related to the introduction of concepts such as “human security” and “sovereignty as responsibility” in the post-cold war era, which tied the capacity of the state to secure its population to that state’s domestic and international legitimacy. Based on a realist understanding of the world, one prominent criticism of this approach was that, as rational self-interested entities, states would only commit resources to human security when they derived some direct benefit from it. Directed at the IHR framework, this critique suggests that the framework is primarily aimed at protecting states, particularly developed states, from the economic and other ills of pandemics and not, in fact, at promoting human security. Expecting core capacities for pandemic prevention to be prioritized in states where, for example, health-care coverage is far from universal has raised the question: who really benefits from the securitization of health?
This question is legitimate but neglects the discussion that has flowed from the health security movement since the 1990s. Today, debates concerning what should follow the Millennium Development Goals (MDGs) are primarily focused on the promotion of universal health care as a core goal.10 In 2007, the Oslo Ministerial Declaration by the Ministers of Foreign Affairs of Brazil, France, Indonesia, Norway, Senegal, South Africa and Thailand suggested 10 implementation priorities which included the marriage of health security with health equality: “a global partnership for overcoming both structural and economic barriers to development and health is fundamental for reaching the MDGs and reducing vulnerabilities to neglected and emerging infectious diseases” (emphasis added).11
This Declaration inspired the adoption of a General Assembly resolution on Global Health and Foreign Policy.12 In December 2012, the General Assembly reinforced the link between security and universality in calling for member States to “recognize the links between the promotion of universal health coverage and other foreign policy issues, such as the social dimension of globalization, cohesion and stability, inclusive and equitable growth and sustainable development and sustainability of national financing mechanisms, and the importance of universal coverage in national health systems”.13
This approach clearly refutes realist cynicism and shows an emerging consensus that health security rests on universal and equitable health systems upon which sustained implementation of the IHR core capacities depend. A key priority then is to ensure that access to and distribution of core capacities is equitable within and across societies and that the progress of IHR does not inadvertently weaken other aspects of the health system.
In South and East Asia, for example, things have progressed amid a number of competing priorities and political interests. The region sits on key trading routes, has already proven to be a hot spot for novel infectious diseases (Severe Acute Respiratory Syndrome (SARS), Dengue Haemorrhagic Fever, severe complications from Enterovirus and influenza strains such as H5N1 and H7N9), has multiple states in political transition, civil unrest, dormant and active armed conflicts, and has a number of states recovering from armed conflict. There is also sharp diversity of wealth, health coverage and health governance.
Since 2004, in the aftermath of SARS, member States to WHO South-East Asia Regional Office (SEARO) and Western Pacific Regional Office (WPRO) began meeting to develop a collective strategy for addressing emerging infectious disease outbreaks. The resulted Asia Pacific Strategy for Emerging Diseases (APSED) framework was adopted in 2005. APSED aimed to assist member States with the implementation of the revised IHR and to develop a series of implementation goals and shared experiences that would reflect regional concerns and realities outside the confines of the IHR. APSED, in its second phase of implementation in 2010-2015, still works according to the principle of tailoring the IHR core capacity requirements to the priorities and capacities of SEARO and WPRO member States.14 WHO SEARO and WPRO staff, along with the Association of Southeast Asian Nations (ASEA N), have worked together in efforts to share dialogue and highlight progress across the eight IHR capacities. From its inception, the APSED framework has been couched in strong security rhetoric, one that the ASEAN secretariat has readily adopted to promote regional cooperation.15,16
However, with this ready adoption of a national security lens have come concerns that the overall approach conceals deep structural shortfalls when it comes to IHR compliance in the region. It is sometimes charged that security rhetoric allows the region to appear engaged while doing little to ensure that domestic health and political systems are reformed to meet the commitments made to IHR .17,18 ,19 These programmes rely on self-reporting and hold workshops that engage like-minded health responders, while there is no forum to openly address problems where progress is seriously lagging.20
In responding to these concerns, while it cannot be said that all member States are effectively achieving their core capacity targets, the region has exhibited a willingness to recognize the challenges it faces. Most notably, nearly every SEARO and WPRO member State has reported on progress towards IHR implementation, a rate of reporting significantly above any of the other WHO Regional Offices. When novel outbreaks occur, this emerging shared knowledge of where capacity and capacity gaps exist is a significant advantage, as the region’s rapid and largely effective response to H7N9 demonstrates. Indeed, WPRO and SEARO have made the most progress in narrowing the time difference between outbreak alert and formal confirmation. This is no small achievement.
There are three key concepts about the relationship between pandemics and security. First, associating health policy commitments with security can elevate the level of priority given to an issue and deliver results. While 110 member States will not meet their IHR core capacities by 2014, the majority of these States are working towards an implementation path with the WHO Director-General. Few other areas of global governance can boast similar levels of commitment and compliance; fewer still where core national capacities and structures are concerned.
Second, health security has not distorted policy by drawing attention away from the health crises that affect most of the world’s population. In fact, heightened global and national interest in pandemic prevention and response has helped to elevate the goal of universal health-care coverage. It is now widely recognized that effective prevention and response to a pandemic requires national health systems that are accessible and equitable. Universal health-care coverage is not the only answer in strengthening health systems but many states, such as China, perceive it as a core part of their effective response to disease outbreak events.
Third, IHR compliance needs to be understood through a regional lens and supported by global institutions. Regional mechanisms allow a more tailored approach that recognize the contexts in which states operate and establish frameworks consistent with regional norms. This all helps to build the necessary trust and confidence. However, regions and individual states cannot do this on their own and WHO has a major role to play in assisting its regional offices and cooperating with its member States. The wider United Nations system, especially bodies such as the Peacebuilding Commission and agencies such as the United Nations Development Programme and United Nations Children’s Fund, have a supporting role to play in helping states build the technical capacities needed to deliver the IHRs.
While the marriage of security and health has helped build the necessary global political will to implement the IHRs, the institutional, technical and political challenges in achieving this goal cannot be overstated.
1 Doshi, P., “The elusive definition of pandemic influenza”, Bulletin of the World Health Organization, vol. 89 (2011), pp. 532-538.
2 World Health Organization, “World Health Assembly adopts new International Health Regulations: New rules govern national and international response to disease outbreaks” (2005).
3 World Health Organization, Revision and Updating of the International Health Regulations, WHA48.7, Forty-eighth World Health Assembly (1995).
4 World Health Organization, Revision of the International Health Regulations, WHA58.3, Fifty-eighth World Health Assembly (2005).
6 World Health Organization, Department of Global Capacities and Alert Response Activity Report, 2012 (WHO Lyon Office, 2013). Available from http://www.who.int/ihr/publications/ WHO_HSE_GCR _ LYO_2013.3.pdf.
7 World Health Organization (2013), Implementation of the International Health Regulations (2005). Report by the Director-General (A/66/16), Sixty-sixth World Health Assembly.
8 Hardiman, Maxwell C. and World Health Organization Department of Global Capacities, Alert and Response, “World Health Organization perspective on implementation of International Health Regulations”, Emerging Infectious Diseases (2012). Available from http://wwwnc.cdc.gov/eid/article/18/7/12-0395_article.htm.
9 See World Health Organization (2013), Implementation of the International Health Regulations (2005).
10 World Health Organization, Informal Member State Consultation on Health in the Post-2015 Development Agenda, Summary Report (2012). Available from http://www.who.int/topics/millennium_development_goals/post2015/summary_... states_20121214.pdf).
11 Ministers of Foreign Affairs of Brazil, France, Indonesia, Norway, Senegal, South Africa and Thailand, “Oslo Ministerial Declaration—global health: a pressing foreign policy issue of our time”, The Lancet (2007).
12 Global health and foreign policy (A/63/33), 27 January 2009.
13 Global health and foreign policy (A/67/L.36, para. 3), 12 December 2012.
14 World Health Organization, “Securing Regional Health through APSED, Building Sustainable Capacity for Managing Emerging Diseases and Public Health Events”, Progress Report (World Health Organization Regional Office for Western Pacific, 2012).
15 Caballero-Anthony, M., “Non-Traditional Security and Infectious Diseases in ASEAN: Going Beyond the Rhetoric of Securitization to Deeper Institutionalisation”, The Pacific Review, vol. 12, No. 4 (2008), pp. 509-527.
16 Haacke, J. and Paul D. Williams, “Regional Arrangements, Securitization, and Transnational Security Challenges: The African Union and the Association of Southeast Asian Nations Compared”, Security Studies, vol. 17, No. 4 (2008), pp. 775-809.
17 Aldis, W., “Health security as a public health concept: a critical analysis”, Health Policy and Planning, vol. 23, No. 6, (2008), pp. 369-375.
18 Stevenson, M. A. and A. F. Cooper, “Overcoming Constraints of State Sovereignty: Global Health Governance in Asia”, Third World Quarterly, vol. 30, No. 7 (2009), pp. 1379-1394.
19 Vu, T., “Epidemics as Politics with Case Studies from Malaysia, Thailand, and Vietnam, Global Health Governance”, (2011) (see http://blogs.shu. edu/ghg/2011/06/21/epidemics-as-politics-with-case-studies-from-malaysia-thailand-and-vietnam/).
20 See Haacke, J. and Paul D. Williams (2008).