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This chapter describes the emergence of “global health security” as a stra-
tegic framework designed to prepare for and respond to the threat of cata-
strophic disease.1 Global health security focuses on “emerging infectious
diseases”— whether naturally occurring or man- made— which are seen
to threaten wealthy countries and which typically (although not always)
emanate from Asia, sub- Saharan Africa, or Latin America. Such pathogens
include severe acute respiratory syndrome (SARS), extremely drug- resistant
(XDR) tuberculosis, and humanly transmissible avian influenza; but what
is crucial is that this framework is oriented toward outbreaks that have not
yet occurred— and may never occur. For this reason, it seeks to implement
techniques of preparedness for events whose likelihood is incalculable but
whose political, economic, and health consequences could be catastrophic.
Its advocates seek to build a real- time, global disease surveillance system that
can provide early warning of potential outbreaks and link such early warn-
ing to tools of rapid response that will protect against their spread to the rest
of the world. To achieve this, global health security initiatives draw together
various organizations including multilateral health agencies, national dis-
ease control institutes, and collaborative reference laboratories and assemble
diverse technical elements such as disease surveillance methods, emergency
operations centers, and vaccine distribution systems.
At the heart of the regime of global health security is a sociotechnical
imaginary (Jasanoff, this volume) concerning the future problem of infec-
tious disease and its possible solutions: it is a future in which outbreaks
of novel diseases continually threaten human life, but catastrophe may be
averted if such events are detected and contained in their earliest stages.2
To justify ongoing investment in pandemic preparedness, an envisioned
outbreak must remain on the near- term horizon; it is thus urgent to enact
FOURTEEN
Global Health Security and the
Pathogenic Imaginary
ANDREW LAKOFF
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Global Health Security and the Pathogenic Imaginary / 301
adequate security measures. And importantly, these security measures must
be “global” in extent (Miller, this volume), since the perceived threat of
emerging disease transcends national boundaries. Despite the force of this
imaginary, this global governance regime does not command universal as-
sent. As the chapter will show, its extension is challenged both by existing
national agencies that have historically exercised public health responsibili-
ties and by alternative cosmopolitan visions of the problem of global health.
To establish its legitimacy, global health security must address a number of
questions, including which populations is it responsible for, how does it
presume to override national authorities, and what epistemic tools enable
it to make authoritative claims?
The chapter begins with a summary of the historical emergence of global
health security in relation to the problematic, initially articulated in the late
1980s, of emerging infectious disease. It then looks at the development of
a specific governance tool for managing outbreaks of new pathogens on a
global scale, the International Health Regulations (IHR), as they were revised
in 2005. Protocols for monitoring and responding to outbreaks codified by
the revised IHR were at the heart of two recent global health controversies:
one around the Indonesian government’s refusal to share avian influenza
virus strains with a global disease monitoring system and another around
the question of whether the World Health Organization (WHO) exaggerated
the threat posed by the 2009 swine flu outbreak. The chapter takes up these
two controversies in turn as cases for understanding the tensions sparked by
the consolidation of global health security as a global governance regime.
The Objects and Aims of Global Health Security
A 2007 report from the WHO articulated the objects and aims of global
health security.3 The report, entitled “A Safer Future: Global Public Health
Security in the 21st Century,” began by noting the success of traditional
public health measures during the twentieth century in dealing with dev-
astating infectious diseases such as cholera and smallpox. But in recent de-
cades, the report continued, there had been an alarming shift in the “deli-
cate balance between humans and microbes” (WHO 2007, 1). A series of
factors— including demographic changes, economic development, global
travel and commerce, and conflict— had “heightened the risk of disease out-
breaks,” ranging from new infectious diseases such as HIV/AIDS and drug-
resistant tuberculosis to food- borne pathogens and bioterrorist attacks.4
The WHO report proposed a strategic framework for responding to this
new landscape of threats, which it called “global public health security.”
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302 / Andrew Lakoff
The framework emphasized a terrain of global health that was distinct from
the predominantly national organization of classical public health. “In the
globalized world of the 21st century,” the report began, simply stopping dis-
ease at national borders was not adequate. Nor was it sufficient to respond
to diseases after they had become established in a population. Rather, it was
necessary to prepare for unknown outbreaks in advance, something that
could be achieved only “if there is immediate alert and response to disease
outbreaks and other incidents that could spark epidemics or spread globally
and if there are national systems in place for detection and response should
such events occur across international borders” (WHO 2007, 11).
As envisioned by WHO, the framework of global health security was a
culmination of two decades of increasing concern over the problematic of
“emerging infectious disease.” This problematic was initially raised by a
group of United States– based infectious disease experts in the late 1980s
and early 1990s (King 2002). In 1989, molecular biologist Joshua Leder-
berg and virologist Stephen Morse hosted a conference on the topic, which
led to the landmark volume, Emerging Viruses (Morse 1993). Lederberg and
Morse shared an ecological vision of disease emergence as the result of en-
vironmental transformation combined with increased global migration.5
Participants in the conference warned of a dangerous intersection. On the
one hand, they pointed to a number of new disease threats, including novel
viruses such as HIV and Ebola as well as drug- resistant strains of diseases
such as tuberculosis and malaria. On the other hand, participants argued,
public health infrastructures worldwide had been allowed to decay with the
assumption that the problem of infectious disease had been conquered.
Moreover, the emergence and spread of new infectious diseases could be
expected to continue, owing to a number of processes of global transforma-
tion, such as increased travel, urbanization, civil wars and refugee crises,
and environmental destruction. For these experts, the AIDS crisis heralded
a dangerous future in which more deadly pathogens were likely to appear.
Over the ensuing years, alarm about emerging disease threats came from
various quarters, including scientific reports by prominent organizations
such as the Institute of Medicine (1992), the reporting of science journalists
such as Laurie Garrett (1994), and the dire scenarios of writers such as Rich-
ard Preston (1998). For a number of health experts, the emerging disease
threat— particularly when combined with weakening national public health
systems— marked a troublesome reversal in the history of public health. At
just the moment when it seemed that the threat posed by infectious disease
had waned and that the critical health problems of the industrialized world
now mainly involved chronic disease, these experts warned that we were
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Global Health Security and the Pathogenic Imaginary / 303
witnessing a “return of the microbe.” It is worth emphasizing the expan-
sive character of the category of “emerging infectious disease.” The category
made it possible to bring HIV into relation with a range of other microbial
threats, including viral hemorrhagic fevers, West Nile virus, dengue, and
drug- resistant strains of malaria and tuberculosis. It also pointed toward the
imperative to develop means of anticipatory response that could approach
a disparate set of disease threats.
In an initial stage of discussion, authorities proposed to address the
problem of emerging infectious disease using tools of disease eradication
that had been developed as part of Cold War– era international health, such
as disease surveillance, outbreak investigation, and containment. For in-
stance, one contributor to Emerging Viruses was epidemiologist D.A. Hen-
derson, who had implemented techniques of disease surveillance in the
1960s and 1970s as director of the WHO Smallpox Eradication Program.
For Henderson, the problem posed by emerging infections was not one of
prevention but rather one of vigilant monitoring. He argued that pathogen
emergence was inevitable, that “mutation and change are facts of nature,
that the world is increasingly interdependent, and that human health and
survival will be challenged, ad infinitum, by new and mutant microbes, with
unpredictable pathophysiological manifestations” (Henderson 1993, 283).
As a result, “we are uncertain as to what we should keep under surveillance,
or even what we should look for.” What we need, he continued, is a system
that can detect novelty: in the case of AIDS, such a detection system could
have provided early warning of the new virus and made it possible to put in
place measures to limit its spread. Henderson proposed a network of global
disease surveillance units to be run by the US Centers for Disease Control
and Prevention (CDC), which would be located in periurban areas in major
cities in the tropics.
At around this time, the emerging disease problematic entered US na-
tional security discussions. Beginning in the mid- 1990s, US national security
officials began to focus on bioterrorism as one of a number of “asymmetric
threats” the nation faced in the wake of the Cold War. They hypothesized
an association among rogue states, global terrorist organizations, and the
proliferation of weapons of mass destruction (Wright 2006). Reports during
the 1990s about secret Soviet and Iraqi bioweapons programs, along with
the Aum Shinrikyo subway attack in Tokyo in1995, lent credibility to calls
for biodefense measures focused on the threat of bioterrorism. Early advo-
cates of such efforts, including infectious disease experts such as Henderson
and national security officials such as Richard Clarke, argued that adequate
preparation for a biological attack would require a massive infusion of re-
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304 / Andrew Lakoff
sources into both biomedical research and public health response capac-
ity.6 More broadly, they maintained, it would be necessary to incorporate
the agencies and institutions of the life sciences and public health into the
national security establishment. In the 1990s, Henderson and others con-
nected the interest in emerging diseases among international health spe-
cialists with US national security officials’ concern about the rise of bioter-
rorism, suggesting that a global disease surveillance network could serve to
address both problems.
Epidemic Intelligence
Henderson’s model of disease surveillance was a product of his background
at the Epidemic Intelligence Service (EIS) based at the CDC.7 The EIS ap-
proach, introduced in the 1950s by Henderson’s mentor Alexander Lang-
muir, was one of “continued watchfulness over the distribution and trends
of incidence through systematic consolidation and evaluation of morbidity
and mortality data and other relevant data,” as Langmuir (1963, 182– 3)
put it.8 Henderson had used this method in tracking the global incidence of
smallpox as director of the WHO eradication program. His proposed global
network of surveillance centers and reference laboratories extended this ap-
proach to as- yet- unknown diseases, providing early warning for response
to outbreaks of any kind— whether natural or man- made. Stephen Morse
(1992, 29) summarized the justification for “expanding permanent surveil-
lance programs to detect outbreaks of disease” in terms of the shared needs
of international health and national security: “A global capability for recog-
nizing and responding to unexpected outbreaks of disease, by allowing the
early identification and control of disease outbreaks, would simultaneously
buttress defenses against both disease and CBTW [chemical, biological, and
toxin warfare].”
This epidemic intelligence approach to emerging infections was institu-
tionalized at a global scale over the course of the 1990s as experts from CDC
brought the methods and assumptions of EIS into the WHO. The career of
epidemiologist David Heymann is instructive. Heymann began his profes-
sional service in EIS, and in the 1970s worked with CDC on disease outbreak
containment in Africa and with WHO on the smallpox eradication program
(Ashraf 2004). In the early years of the AIDS pandemic, he helped establish
a WHO office to track the epidemiology of the disease in developing coun-
tries. He then returned to Africa in 1996 to lead the agency’s response to a
widely publicized Ebola outbreak in Congo. After this he was asked by the
director of WHO to set up a program in emerging diseases. “At this time
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Global Health Security and the Pathogenic Imaginary / 305
there was an imbalance in participation internationally in the control of
emerging and re- emerging infectious diseases,” he later recalled, “the bur-
den was falling mainly on the USA” (Ashraf 2004, 787). At WHO, Heymann
set up a global funding mechanism that broadened the agency’s emerging
disease surveillance and response capacities along the CDC model. He and
his colleagues soon identified a specific problem to be addressed: how to
ensure the compliance of national health agencies with the demands of
global health surveillance?
In the wake of the Ebola outbreak, as well as catastrophic outbreaks of
cholera in Latin America and plague in India in the early 1990s— now under-
stood as “reemerging diseases”— a “need was identified” for stronger inter-
national coordination of response, as Heymann (2004, 1127) later reflected.
A major problem for outbreak investigators was that national governments
often did not want to report the incidence of a disease that could harm tour-
ism and international trade. The case of the plague outbreak in Surat in 1994,
in which Indian officials suppressed international reporting of the event,
exemplified the impossibility of forcing countries to publicly report disease
emergencies.9 Although, as Heymann put it, “in our emerging diseases pro-
gram our idea was to change the culture so that countries could see the ad-
vantage of reporting,” a practical means of enforcing compliance was needed.
A potential means of such enforcement soon arose from an unexpected
source: the creation, during the 1990s, of Internet- based reporting systems
such as ProMED in the United States and GPHIN in Canada that scoured
international media for stories about possible outbreaks. The development
of these digital information networks meant that global public health au-
thorities did not have to rely exclusively on official, nation- state– based
epidemiological reporting (Weir and Mykhalovskiy 2007). In 1997, WHO
established GOARN (Global Outbreak Alert and Response Network), a
network that linked together individual disease surveillance and response
systems, which eventually had 120 partners. The resulting potential for the
rapid circulation of infectious disease information across national borders
undermined national governments’ traditional control of public health
knowledge, making a global form of disease surveillance possible.
The outbreak of SARS in 2002 in China provided Heymann and his col-
leagues in WHO’s Emerging Infections branch with an opportunity to test
the new disease reporting system. As an unknown and unexpected but po-
tentially catastrophic viral disease, SARS fit well into the existing category of
emerging infections (Hooker 2007). The Chinese government’s initial reluc-
tance to fully report the outbreak to global health authorities led WHO to
rely on its new capacity to use nonstate sources of information: SARS was the
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306 / Andrew Lakoff
first time the GOARN network identified and publicized a rapidly spreading
epidemic. As opposed to recalcitrant national governments, Heymann later
reflected, international scientists “are really willing to share information for
the better public good” (Ashraf 2004, 787). GOARN made it possible to
electronically link leading laboratory scientists, clinicians, and epidemiolo-
gists around the world in a “virtual network” that rapidly generated and
circulated knowledge about SARS. WHO tracked the spread of the illness
closely and issued a series of recommendations on international travel re-
strictions. According to Heymann, who led the WHO response, this rapid re-
action was key to the containment of the epidemic by July 2003— although
he also acknowledged the good fortune that SARS had turned out not to be
easily transmissible.
The lesson Heymann drew from the experience of SARS was that, in a
closely interconnected and interdependent world, “inadequate surveillance
and response capacity in a single country can endanger the public health se-
curity of national populations and in the rest of the world” (Heymann 2004,
1128). SARS thus confirmed the pathogenic imaginary of global health se-
curity. Processes of globalization, including migration, ecological transfor-
mations, and massive international travel, had led to new biological, social,
and political risks— risks that transcended national borders and therefore
could not be ignored by wealthy countries. Only a global system of rapidly
shared epidemiological information could provide adequate warning in
order to mitigate such risks. National sovereignty must accede to the de-
mands of global health security. This vision was then applied to the next
potential disease emergency, highly pathogenic avian influenza.
The Next Pandemic: H5N1
The space of emerging disease, initially carved out by AIDS and then ex-
panded by SARS, was soon occupied by a new threat: the possibility that
a deadly new strain of H5N1 avian influenza would mutate or reassort to
become easily transmissible among humans. The risk of such an event could
not be calculated using statistical data on historical incidence (since it had
not yet occurred), but its occurrence could, experts warned, be catastrophic.
As of 2005, when global pandemic flu preparedness efforts intensified,
H5N1 had killed nearly 60 percent of those who had contracted it, and was
spreading globally among migratory birds and domesticated poultry.
In an article published in Foreign Affairs, journalist Laurie Garrett evoked
both the dire scenario of an H5N1 pandemic and the uncertainty surround-
ing it: “In short, doom may loom. But note the ‘may.’ If the relentlessly evolv-
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Global Health Security and the Pathogenic Imaginary / 307
ing virus becomes capable of human- to- human transmission, develops a
power of contagion typical of human influenzas, and maintains its extra-
ordinary virulence, humanity could well face a pandemic unlike any ever
witnessed. Or nothing at all could happen” (Garrett 2005). Others were less
circumspect in their warnings. “It is not a question of if, but when,” declared
infectious disease expert Michael Osterholm (2005). “I believe an influenza
pandemic will be like a 12– 18 month global blizzard that will ultimately
change the world as we know it today.” The prospect of such global catas-
trophe lent urgency to the enactment of pandemic preparedness measures,
including the adoption of major revisions to the venerable IHR.
Governing Global Health Emergencies
According to legal scholar David Fidler (2005, 326), the 2005 IHR revision
was “one of the most radical and far- reaching changes in international law
on public health since the beginning of international health co- operation in
the mid- nineteenth century.” For my purposes here, the revised IHR are best
understood as a significant element in the emerging framework of global
health security. The revised IHR instituted a new set of legal obligations for
nation- states to accept global intervention in a world seen as under threat
from ominous pathogens circulating ever more rapidly.
The IHR system, dating from the 1851 International Sanitary Law, defines
states’ mutual obligations in the event of an outbreak of a dangerous com-
municable disease. Historically, its function has been to guarantee the con-
tinued flow of international trade during epidemics, ensuring that countries
not take overly restrictive measures in response to the threat of infection. In
the context of concern over emerging infectious diseases, the existing IHR
had proven ineffectual in forcing disease notification for at least two rea-
sons. For one, its limited list of reportable conditions— cholera, plague, and
yellow fever— was of little relevance for the expansive category of emerging
infections; second, the existing regulations did not have a mechanism to
enforce national compliance with IHR reporting requirements.
The revision of IHR became a vehicle for outbreak investigators to con-
struct the global disease surveillance system that had been proposed by Hen-
derson and others. WHO authorities proposed three key innovations to IHR
that would make it possible for the agency to manage a range of potential
disease emergencies. The first innovation responded to the problem of the
narrow range of disease events covered by the existing IHR. Through the
invention of the concept of the “public health emergency of international
concern” (PHEIC), the revised regulations vastly expanded the kinds of
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308 / Andrew Lakoff
events to which the regulations might apply. According to the “IHR Decision
Instrument” (WHO 2008, 43), naturally occurring infectious diseases such
as pandemic influenza and Ebola, intentional releases of deadly pathogens
such as smallpox, or environmental catastrophes such as those that occurred
at Bhopal in 1984 and Chernobyl in 1986 could all provoke the declaration
of a PHEIC. The IHR decision instrument was designed to guide states in
determining what would constitute a public health emergency that required
the notification of WHO. However, as we will see below, the pathway in the
instrument defined as “any event of international public health concern” left
considerable room for interpretation of the scope of the regulations.
The second major innovation in the revised IHR responded to the prob-
lem of national health agencies’ monopoly on epidemiological data. The
new regulations expanded the potential sources of authorized reports of
outbreaks: whereas the prior IHR had restricted official reporting to national
governments, the revised IHR allowed WHO to recognize reports from non-
state sources such as digital and print media. In this way, state parties’ un-
willingness to report outbreaks would not necessarily impede the function-
ing of the system. The premise was that, with WHO’s official recognition of
nonstate monitors such as GOARN, reports of outbreaks could no longer be
suppressed by national governments and so it would be in states’ interest
to allow international investigators into the country as soon as possible in
order to undertake disease mitigation measures and to assure the public that
responsible intervention was underway.
The third innovation of the revised IHR addressed the problem of devel-
oping countries’ ability to monitor and respond to outbreaks. It required
that all WHO member states build national capacity for infectious disease
surveillance and response. The construction of “national public health in-
stitutes” on the model of the US CDC would make possible a distributed
global network that relied on the functioning of nodes in each country.
The impetus for such institutes as part of the WHO Global Health Security
framework should be distinguished from prior modernizing efforts to build
public health systems in the developing world. IHR’s reliance on national
health systems did not necessarily imply strengthening governmental capac-
ity to manage existing disease; rather, it sought to direct the development of
outbreak detection systems according to the needs of global disease surveil-
lance.10 WHO gave countries until 2016 to fulfill this obligation. However,
it was unclear where the resources would come from to implement systems
for detecting the onset of emerging diseases in poor countries that already
had trouble managing the most common ones.
By 2007, with the official implementation of the revised IHR, accompa-
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Global Health Security and the Pathogenic Imaginary / 309
nied by the release of the WHO Report on “Global Public Health Security
in the 21st Century” (described above), the new framework for governing
global health emergencies was in place. However, the intensive buildup of
preparedness efforts in anticipation of a catastrophic disease outbreak did
not go unchallenged. In the remaining portion of the chapter, I focus on
two controversies sparked by the consolidation of the global health security
framework. The first controversy centered on the political question of whose
health was to be protected by the new governance regime; and the second
focused on the epistemological question of how to know what constitutes
a catastrophic health risk.
Viral Sovereignty
In an opinion piece published in the Washington Post in August 2008, dip-
lomat Richard Holbrooke and science journalist Laurie Garrett mounted a
sharp attack on what they called “viral sovereignty” (Holbrooke and Garrett
2008). By this term, the authors referred to the “extremely dangerous” idea
that sovereign states could exercise ownership rights over samples of viruses
found in their territory. Specifically, Holbrooke and Garrett were incensed
by the Indonesian government’s refusal to share samples of H5N1 avian in-
fluenza with the WHO’s Global Influenza Surveillance Network (GISN). For
over fifty years, this network had collected samples of flu viruses from refer-
ence laboratories around the world and used these samples to determine the
composition of yearly flu vaccines. More recently, the network had tracked
the transformations of avian influenza viruses as a means of assessing the
risk of a deadly global pandemic.11 International health experts feared that
the new strain of H5N1, which had already proven highly virulent, would
mutate to become easily transmissible among humans— in which case a
worldwide calamity could be at hand. GISN thus served as a global “early
warning system” enabling experts to track genetic changes in the virus that
could potentially lead to a catastrophic disease event.
As the country where the most human cases of avian influenza had been
reported, Indonesia was a potential epicenter of such an outbreak. For this
reason, the country’s decision to withhold samples of the virus undermined
GISN’s function as a global early warning system. From Holbrooke and
Garrett’s vantage, which assumed the imaginary of global health security,
Indonesia’s action posed a significant threat to the world. “In this age of
globalization,” they wrote, “failure to make viral samples open- source risks
allowing the emergence of a new strain of influenza that could go unnoticed
until it is capable of exacting the sort of toll taken by the pandemic that
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310 / Andrew Lakoff
killed tens of millions in 1918” (Holbrooke and Garrett 2008). According
to Holbrooke and Garrett, Indonesia had not only a moral but also a legal
obligation to share its viruses with the WHO. They argued that the country’s
action was a violation of the newly revised IHR, which held the status of an
international treaty for WHO member states.
The opinion piece suggested that the rational and beneficent technocracy
of the WHO was faced with antiscientific demagoguery that threatened the
world’s health. Holbrooke and Garrett painted a picture of the Indonesian
Health Minister, Siti Fadilah Supari, as an irrational populist who sought
to make domestic political gains through unfounded attacks on the United
States and the international health community. Indonesia was apparently
withholding these virus samples based on the “dangerous folly” that these
materials should be protected through the same legal mechanism that the
United Nations Food and Agriculture Organization used to guarantee poor
countries’ rights of ownership to indigenous agricultural resources— the
Convention on Biological Diversity. Further, Holbrooke and Garrett rebuked
Supari’s “outlandish claims” that the US government was planning to use
Indonesia’s H5N1 samples to design biological warfare agents— echoing US
Secretary of Defense Robert Gates’s reaction upon hearing this accusation
during a visit to Jakarta: “the nuttiest idea I’ve ever heard” (Agence- France
Press 2008).
The controversy over influenza virus sharing was, it turned out, some-
what more complicated than Holbrooke and Garrett allowed. Beginning in
late 2006, at Supari’s behest, the Indonesian Health Ministry had stopped
sharing with the GISN isolates of H5N1 found in patients who had died of
avian influenza. The source of Supari’s ire was the discovery that an Austra-
lian pharmaceutical company had developed a patented vaccine for avian
flu using an Indonesian strain of the virus— a vaccine that would not be
affordable for most Indonesians in the event of a deadly pandemic. More
generally, given the limited number of vaccine doses that could be produced
in time to manage such a pandemic— estimates were in the 500 million
range— experts acknowledged that developing countries would have little
access to such a vaccine. In other words, while Indonesia had been delivering
virus samples to WHO as part of a collective early warning mechanism (i.e.,
GISN), they would not be beneficiaries of the biomedical response appara-
tus that had been constructed to prepare for a deadly global outbreak. For
the Indonesian health minister, this situation indicated a dark “conspiracy
between superpower nations and global organizations” (Schnirring 2008).
While less suspicious of US and WHO intentions than Supari, a number
of Western journalists and scientists were sympathetic to the Indonesian
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Global Health Security and the Pathogenic Imaginary / 311
position, on the grounds of equity in the global distribution of necessary
medicines. A Time magazine article noted that “they had a point; poor devel-
oping nations are often priced out of needed medicines, and they’re likely to
be last in line for vaccine during a pandemic” (Walsh 2007). An editorial in
the Lancet (2007, 1763) argued, “to ensure global health security, countries
have to protect the wellbeing not only of their own patients but also those
of fellow nations.” Anxious to secure the operation of its global influenza
surveillance apparatus, WHO was willing to strike a bargain: at a World
Health Assembly meeting in 2007, members agreed to explore ways of help-
ing poorer countries to build vaccine production capacity. But the financial
and technical details of how such a system would function were opaque,
and the issue remained unresolved until a settlement was reached in 2011.12
In October 2008, as Indonesia continued to withhold the vast majority of
its virus samples from GISN, Agence- France Presse (2008) reported that “Su-
pari does appear to be vindicated by a flood of patents being lodged on the
samples of H5N1 that have made it out of Indonesia, with companies in de-
veloped countries claiming ownership over viral DNA taken from sick Indo-
nesians.” The Australian drug company CSL acknowledged that it had used
Indonesian bird flu strains to develop a trial vaccine but insisted that it had
no obligation to compensate Indonesia or guarantee access to the vaccine.
A good deal more could be said about this controversy (see, e.g., Lowe
2010), but I want to focus here on just one aspect of Holbrooke and Garrett’s
attack: their accusation that Indonesia was in violation of the newly revised
IHR. International law experts saw the virus- sharing controversy as an early
test of how well the revised IHR would function. According to the new regu-
lations, IHR signatories were required to provide WHO with “public health
information about events that may constitute a PHEIC” (Fidler 2008). In the
case of the virus- sharing controversy, the central legal question was whether
biological materials constituted such “public health information.” Plausible
arguments could be made on both sides. At the May 2007 meeting of the
World Health Assembly, WHO Director General Margaret Chan claimed,
“countries that did not share avian influenza virus would fail the IHR”
(Fidler 2008). The US delegation agreed: “All nations have a responsibility
under the revised IHRs to share data and virus samples on a timely basis
and without preconditions” (Fidler 2008). Thus, the United States argued,
“our view is that withholding influenza viruses from GISN greatly threatens
global public health and will violate the legal obligations we have all agreed
to undertake through our adherence to IHRs.” However, as Fidler noted,
the relevance of the revised IHR to the specific issue of virus sharing was
ambiguous: the new regulations explicitly referred only to a requirement to
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312 / Andrew Lakoff
share public health information, such as case reports and fatality rates, and
the case could be made that biological materials such as virus samples were
distinct from such information.
In any case, the Indonesian Health Ministry’s response came from out-
side the legal framework of IHR. Rather, Supari argued that the global virus
sharing system was ethically compromised and in need of reform. “We want
to change the global virus- sharing mechanism to be fair, transparent and
equitable,” Supari said in an interview defending the government’s deci-
sion to withhold the virus (Agence- France Presse 2008). “What we mean by
fair is that any virus sharing should be accompanied by benefits derived
from the shared virus, and these benefits should be coming from the vaccine
producing countries.” Supari was speaking from within a different socio-
technical imaginary than that of the WHO’s framework of “global public
health security,” which the revised IHR was designed to serve. In speaking of
benefits sharing, Supari was invoking a mechanism intended to encourage
development— the Convention on Biological Diversity— in order to ground
a rhetoric of national sovereignty that ran counter to the transnational au-
thority of the WHO. But her attack on the high price of patented vaccines
also resonated with demands for equal access to life- saving medicines com-
ing out of the humanitarian global health movement (Redfield 2013).
A technical and political system designed to prepare for potentially cata-
strophic disease outbreaks was facing a very different demand: a call for ac-
cess to essential medicines based on a vision of global equity. The potential
for a deadly outbreak of avian influenza had led to an encounter between
two different ways of imagining the problem of global health— an encoun-
ter that was taking place in the absence of an actual health emergency. At
stake was not only the issue of how best to respond to a global outbreak of
H5N1, but more broadly, how to define the political obligation to care for
the health of populations in a globalizing world in which the capacity of
national public health authorities to protect their fellow citizens’ well- being
was increasingly in question.
Preparing for the Wrong Virus
By 2009, public attention to the threat of an avian influenza pandemic had
begun to wane. However, the regime of pandemic preparedness that had
been put in place to anticipate its arrival remained in a state of vigilance
within national and global public health agencies. And the scenarios that
had been generated to manage its potential occurrence took on new life when
a different virus emerged: A/ H1N1 or swine flu. The strong global response
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Global Health Security and the Pathogenic Imaginary / 313
to what turned out to be a relatively weak virus led to a major controversy
around the legitimacy of global health security— that is, of the practice of
ongoing, intensive anticipation of the onset of a catastrophic disease event.
When the newly reasserted influenza virus A/ H1N1 made its appearance
among humans in April 2009, it seemed at first to be the pathogen the global
health community had been anticipating. Dozens had apparently died in
Mexico from a respiratory ailment, and hundreds more were hospitalized.
Reports of cases from around the United States indicated rapid transmis-
sion of the virus. There was a possibility that the outbreak would become a
deadly pandemic, but its key statistical characteristics— in particular, its case
fatality ratio— were not yet known. Within weeks an extensive public health
apparatus had taken hold of the virus, tracking its global extension through
reference laboratories, mapping its genomic sequence, collating data on
hospitalization and death rates, working to distribute antiviral medicines
and develop a vaccine, and communicating risk to various publics. While
some elements of this apparatus were decades old, such as GISN and the
egg- based technique of vaccine production— others were quite new, such
as Internet- based outbreak reporting systems, molecular surveillance, and
national pandemic preparedness plans.
On April 25, based on reports from Mexico and the United States, WHO
Director- General Margaret Chan declared a PHEIC under the newly revised
IHR. Following IHR protocol, Chan appointed an Emergency Committee
consisting of recognized influenza experts, who recommended a Phase Four
Pandemic Alert. Given the controversy that ensued, it is important to point
out that the definition of “pandemic” from WHO’s 2009 preparedness guid-
ance document referred to “sustained community- level outbreaks” in mul-
tiple regions but made no reference to the severity of the virus (WHO 2009).
Four days later, on April 29, the Emergency Committee voted to raise the
pandemic alert level to Phase Five, indicating that national health authori-
ties should move from “preparedness” to “response” activities. Chan assured
members of the public that WHO was tracking the emerging pandemic at
multiple registers— clinical, epidemiological, and virological— and advised
national health ministers to “immediately activate their pandemic plans”
(Chan 2009a). For North American and European governments, this meant
among other things triggering advanced purchase agreements with vaccine
manufacturers to produce millions of doses in time for anticipated fall im-
munization campaigns. At this early stage of the pandemic, in the absence of
epidemiological data on the severity of the virus, the pandemic alert system
alongside national preparedness plans provided government officials with
guideposts for action.13
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314 / Andrew Lakoff
On June 11, Chan announced pandemic alert Phase Six, a full global
pandemic. In her public statement, she pointed to the agency’s ongoing
vigilance as the event unfolded: “No previous pandemic has been detected
so early or watched so closely, in real- time, right at the very beginning. The
world can now reap the benefits of investments, over the past five years, in
pandemic preparedness” (Chan 2009b). At the same time, she also warned
of ongoing uncertainty: “The virus writes the rules and this one, like all in-
fluenza viruses, can change the rules, without rhyme or reason, at any time.”
Vigilant watchfulness would continue to be necessary.
As of early July, experts were still trying to figure out what H1N1’s rules
were, in particular its rules of transmissibility and virulence. A critical prob-
lem remained the lack of data on the overall incidence, as opposed to the
number of fatalities, of H1N1 in the population. This was the well- known
“problem of the denominator.” A Harvard- based team of epidemiologists
argued for immediate investment in serologic surveys so that the case fatality
ratio could be calculated: “Without good incidence estimates,” they wrote,
“estimates of severity will continue to suffer from an unknown denominator.
The effectiveness of control measures will be difficult to assess without ac-
curate measures of local incidence” (Lipsitch et al. 2009). The Director of the
US Institute of Medicine described such efforts as “epidemic science in real
time,” through which “scientists can enable policies to be adjusted appro-
priately as an epidemic scenario unfolds” (Fineberg and Wilson 2009, 987).
Meanwhile, significant political and economic decisions had to be made
in the absence of fully elaborated data on risk. The alternative was to invest
in preparedness for the worst case. Beginning in the summer 2009, the US
government spent $1.6 billion on 229 million doses of vaccine in what the
Washington Post later called “the most ambitious immunization campaign
in US history” (Stein 2010). In the early fall, unanticipated delays in vac-
cine production combined with high demand led to widespread confusion
and criticism, which faded as the anticipated wave of H1N1 arrived without
causing a catastrophic number of deaths.
In Europe, when the fall wave of H1N1 arrived, the apparent mildness
of the virus led to widespread public skepticism about state- led vaccination
campaigns. The French government spent an estimated 500 million euros
on a campaign that in the end succeeded in immunizing only 10 percent
of the national population. By the winter, the governments of France, Ger-
many, and England all sought to renegotiate their advanced purchase agree-
ments with vaccine manufactures and to unload their excess doses on poor
countries in the global south at bargain prices.
A series of political controversies then erupted in Europe over the inten-
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Global Health Security and the Pathogenic Imaginary / 315
sive public health response to H1N1. In Le Monde, former French Red Cross
president Marc Gentilini admonished the French government for its spend-
ing on the immunization campaign, noting that “preparing for the worst
wasn’t necessarily preparing correctly” (Chaon 2010). A physician and legis-
lator for the governing conservative party decried the misallocation of public
health resources, saying “the cost is more than the deficit of all France’s
hospitals and is three times [the amount spent] on cancer care” (Daneshkhu
and Jack 2010). The French government, in turn, defended its actions on
the grounds of precaution: “I will always prefer to be too prudent than not
enough,” said President Sarkozy (Whalen and Gauthier- Villars 2010).
The attention of critics then turned to the warnings from international flu
specialists that had led national health ministries to implement mass vac-
cination campaigns. As Gentilini put it, “I don’t blame the health minister,
but the medical experts. They created an apocalyptic scenario. There was
pressure from the World Health Organization, which began waving the red
warning flags too early” (Public Radio International 2010). The head of the
French Socialist Party demanded a parliamentary inquiry, calling the vacci-
nation campaign a “fiasco” and arguing that multinational drug companies
were “the big winners in this affair” (Daneshkhu and Jack 2010).
The Chair of the Council of Europe’s Health Committee, a German phy-
sician, convoked public hearings on the matter, charging that the WHO pan-
demic declaration was “one of the greatest medical scandals of the century”
(Macrae 2010). Witnesses before the committee argued that scarce health
resources had been squandered on a virus that turned out to be less danger-
ous than seasonal flu and that such resources should have been spent on
“real” killers, whether heart disease in wealthy countries or infant diarrhea
in poor ones. A German epidemiologist cited annual mortality statistics to
criticize the WHO’s emphasis on managing potential outbreaks at the ex-
pense of treating the actual “great killers” whose toll was attested to by epi-
demiological data: “I would like to point out that of the 827,155 deaths in
2007 in Germany about 359,000 come from cardiovascular diseases, about
217,000 from cancer, 4968 from traffic accidents, 461 from HIV/AIDS and
zero from SARS or Avian Flu” (Keil 2010). Here, coming from one segment
of public health experts, we find the public display of numbers to make the
case that rational intervention must be based on risk calculation rather than
on precaution against potential catastrophe. This reflected distrust, on the
part of certain European health officials, of one of the fundamental premises
of global health security: the need for ongoing vigilance against the onset of
an event that has never before occurred.
But rather than see the WHO as engaged in a different type of reasoned
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316 / Andrew Lakoff
action, one oriented to preparedness for potential catastrophe, critics decried
a lack of objectivity or even corruption, insisting that conflicts of interest
among members of the Emergency Committee had led to the pandemic
declaration. One source of their suspicion was the removal of the measure-
ment of severity from the WHO preparedness guidance document several
months before the appearance of H1N1. In June, an investigative report in
the British Medical Journal revealed paid consulting relations between lead-
ing influenza experts and vaccine manufacturers (Cohen and Carter 2010).
The same week, the Council of Europe released its report, concluding that
the pandemic declaration had led to “a distortion of priorities of public
health services across Europe, waste of huge sums of public money, [and
the] provocation of unjustified fears among Europeans,” and suggesting
that WHO deliberations had been tainted by unstated conflicts of interest
between experts and the drug companies that profited from the vaccine cam-
paign (Parliamentary Assembly 2010).
In response to these allegations, Director- General Chan chartered a re-
view of the agency’s response under the aegis of IHR. The committee eventu-
ally absolved the WHO influenza experts of overstating the seriousness of
the pandemic and focused in its final report on the demand for precaution-
ary action in the face of an unfolding and uncertain event. “Reasonable criti-
cism can be based only on what was known at the time and not on what was
later learnt,” the committee report argued, pointing out that “the degree of
severity of the pandemic was very uncertain throughout the middle months
of 2009, well past the time, for example, when countries would have needed
to place orders for vaccine” (WHO 2011, 17). In its final report, the commit-
tee emphasized the problem WHO had faced in adjusting to the unexpected:
“Lack of certainty is an inescapable reality when it comes to influenza. One
key implication is the importance of flexibility to accommodate unexpected
and changing conditions.”14 In other words, in the case of a novel pathogen,
the virulence of an encroaching epidemic cannot be determined based on
knowledge of the past.
Rather than being the result of a conflict of interest on the part of the WHO
experts, the agency’s “overreaction” was due to the preparedness plans them-
selves, which were built upon the scenario of a different kind of outbreak.
As an official from the European Center for Disease Prevention and Control
later said, explaining the intensive global response to H1N1, “We were all
planning for the potential mutation of the avian flu over the next three to
five years into a person- to- person transmittable disease.”15 Indeed, it was the
use of the avian flu mutation scenario as a guide to authorized action in the
absence of statistical data about disease risk that had so exercised the WHO’s
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Global Health Security and the Pathogenic Imaginary / 317
critics. As epidemiologist Ulrich Keil, a firm advocate of the comparative risk
approach, testified, “Governments and public health services are paying only
lip service to the prevention of these great killers and are instead wasting
huge amounts of money by investing in pandemic scenarios whose evidence
base is weak” (Keil 2010, 3). And the Council of Europe report echoed this
critique of lack of objective evidence of risk: “It was precisely this lack of
watertight evidence about the influenza phenomenon which led to the fears
of the pandemic being exaggerated and the subsequent disproportionate
response” (Council of Europe 2010, 8).
But it is only from the perspective of traditional public health, which
relies on epidemiological risk data to legitimate action, that such an as-
sessment can be made; from the vantage of the framework of global health
security, when a sign of the envisioned catastrophic future appears, already
existing plans must be put into action. In her September 2010 testimony to
the IHR review committee, Director- General Chan revised her earlier state-
ment about the benefits of investments in preparedness: “The world was bet-
ter prepared for a pandemic than at any time in history. But it was prepared
for a different kind of event than what actually occurred” (Chan 2010). Chan
admitted that dire scenarios based on H5N1 had structured the agency’s
response: “Managing the discrepancy between what was expected and what
actually happened was problematic.”
WHO’s pandemic preparedness planners might have responded to the
Council of Europe’s critical report with this line from philosopher Hans
Jonas (1985, 120), writing about the principle of precaution: “the prophecy
of doom is made to avert its coming, and it would be the height of injus-
tice to later deride the ‘alarmists’ because ‘it did not turn out to be so bad
after all’— to have been wrong may be their merit.” Nonetheless, as we have
seen, in the absence of the anticipated catastrophic event, the sociotechnical
imaginary of global health security finds itself challenged to defend its tools
of anticipatory vigilance and precautionary response.
Notes
1. I would like to thank Sheila Jasanoff and Sang- Hyun Kim for their detailed and help-
ful comments on an earlier draft of this chapter.
2. Jasanoff (this volume) defines sociotechnical imaginaries as “widely accepted and
actively pursued visions of social futures underpinned by expectations of what is
possible, attainable, and worth securing through science and technology.” She urges
analysts to remain “attentive to the ways in which imaginaries frame and represent
alternative futures, relate past and future times, enable or restrict actions, and natural-
ize ways of thinking about possible worlds.”
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318 / Andrew Lakoff
3. This section draws on portions of Collier and Lakoff (2008).
4. Charles Rosenberg (1998) contrasts this new form of “civilizational risk” with those
that sparked early public health efforts, noting that anxieties about the risk of modern
ways of life are here explained not in terms of the city as a pathogenic environment
but in terms of evolutionary and global ecological realities.
5. Warwick Anderson (2004) describes this vision as follows: “Evolutionary processes
operating on a global scale were responsible for the emergence of ‘new’ diseases.
As environments changed, as urbanization, deforestation, and human mobility
increased, so, too, did disease patterns alter, with natural selection promoting the
proliferation of microbes in new niches” (Anderson 2004, 60). He traces its history
to the mid- twentieth- century work of disease ecologists such as Theobald Smith,
Macfarlane Burnet, and René Dubos.
6. As Wright (2006) argues, the very use of the term “weapons of mass destruction” to
link nuclear weapons to biological weapons was a strategic act on the part of biode-
fense advocates.
7. The Epidemic Intelligence Service was founded in 1951 by Alexander Langmuir. For
Henderson’s recollections, see Henderson (2009).
8. Langmuir pioneered a method of epidemiological surveillance designed to track each
instance of a disease within a given territory— one that would serve the needs of both
public health and biodefense. See Fearnley (2010) for an insightful historical analysis.
9. See Garrett, The Coming Plague (1994).
10. As one document suggested, “It is proposed that the revised IHR define the capacities
that a national disease surveillance system will require in order for such emergencies
to be detected, evaluated and responded to in a timely manner” (Fidler 2005, 353).
11. The Director of WHO’s communicable diseases cluster leader, David Heymann, de-
scribed the network as follows: GISN “identifies and tracks antigenic drift and shifts
of influenza viruses to guide the annual composition of vaccines, and provides an
early alert to variants that might signal the start of a pandemic” (Heymann 2004).
12. This was known as the “Pandemic Influenza Preparedness” (PIP) Framework. See
Fidler and Gostin (2011).
13. The WHO preparedness guidance explained the function of the alert system as fol-
lows: “This phased approach is intended to help countries and other stakeholders to
anticipate when certain situations will require decisions and decide at which point
main actions should be implemented” (WHO 2009).
14. Intriguingly, this was the same conclusion that the Review Committee chair, Harvey
Fineberg, had reached in his coauthored book evaluating the much- criticized US
CDC response to swine flu in 1976. See Neustadt and Fineberg (1983).
15. The IHR Review Committee agreed with this assessment: “The response to the emer-
gence of pandemic influenza A (H1N1) was the result of a decade of pandemic plan-
ning, largely centered on the threat of an influenza A (H5N1) pandemic” (WHO 2011).
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