Global Health and the Human Security Agenda

Authored by: Colleen O’Manique

The Ashgate Research Companion to the Globalization of Health

Print publication date:  October  2012
Online publication date:  March  2016

Print ISBN: 9781409409243
eBook ISBN: 9781315613598
Adobe ISBN: 9781317041566




The notion of human security is based on the premise that the individual human being is the only irreducible focus for discourse on security. The claims of all other referents (the group, the community, the state, the region, and the globe) derive from the sovereignty of the human individual and the individual’s right to dignity in her or his life. In ethical terms, the security claims of other referents, including the state, draw whatever value they have from the claim that they address the needs and aspirations of the individuals who make them up. (McFarlane and Khong 2006, 2)

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Global Health and the Human Security Agenda

The notion of human security is based on the premise that the individual human being is the only irreducible focus for discourse on security. The claims of all other referents (the group, the community, the state, the region, and the globe) derive from the sovereignty of the human individual and the individual’s right to dignity in her or his life. In ethical terms, the security claims of other referents, including the state, draw whatever value they have from the claim that they address the needs and aspirations of the individuals who make them up. (McFarlane and Khong 2006, 2)


The concept of human security gained prominence in the 1990s amid some optimism that it might shape a new world order in which ‘freedom from want’ and ‘freedom from fear’ 1 would eclipse the dominant state-centric vision of security focused on the sovereign nation-state and its national interest. Human security has since evolved as a conceptual framework for understanding more complex threats to humans in a rapidly globalizing world. For proponents of the human security paradigm, elevating global health to the status of a human security issue has offered the possibility that a deeper understanding of our mutual vulnerability to global health threats might strengthen commitment to the right to health and to humanity’s collective well-being. Less optimistic observers of the evolving relationship between health and security have observed a dominant focus on a small number of virulent pathogens criss-crossing national borders: pathogens that pose a potential emergency to particular (and largely) western, industrialized nation-states and their economic and geopolitical interests (Ingram 2009; O’Manique and Fourie 2010; Brown 2011). As health and disease have entered the lexicon of globalization more attention is being paid to health as an important foreign policy issue, but with formal inter-state and multi-lateral strategies operating in the context of a world deeply unequal and divided (Ingram 2009, 2085). Competing and overlapping conceptions of (in)security are reflected in contemporary practices of global health governance (see Chapter 11), with significant tension between the conception of health as a human security issue linked to a broader analysis of the ideological and structural forces shaping both the governance of global health and the conditions that shape human health, and the more hegemonic view of health as a national security issue in which our increasingly globalized world is producing new pathogens that threaten particular interests of nation-states.

While every country in the world has ratified at least one human rights treaty that addresses the right to health and a number of rights related to the conditions necessary for human health (WHO 2011) the exercise of that right remains elusive for hundreds of millions of people (Chapman, this volume). The emergent global health security agenda has been marked by a pre-occupation with the link between disease and national security, this, part and parcel of post-Cold War attention to non-military threats to peace and state stability. New pathogenic threats to populations have joined terrorism, environmental catastrophe, ‘natural’ disasters and the current global financial crisis in contributing to the normalization of a culture of fear and insecurity. Suddenly we believe, we are all vulnerable. Appeals to the dangers that specific pathogens pose for the national interest are in tension with appeals that point to the implications of broader global health threats for all of humanity – the chronic and non-communicable diseases of the global south, the erosion of the social determinants of health, the deepening of market relations in the provision of basic health services – and the need for cooperation and truly multi-lateral approaches to human health (O’Manique and Fourie 2010, 248).

This chapter focuses on how global health has evolved as a security issue and some of the ways in which global health policies have been shaped by security concerns. I argue that while a human security framework offers a holistic and critical lens through which to understand current threats to human health, the dominant policy responses to health security have undermined the human security threshold of improved health conditions for all people (MacLean, Black and Shaw 2006). As Tim Brown (2011) argues, with humanity’s increased vulnerability to health threats that have no borders, ‘the stated desire to achieve global health security appears to be skewed in favor of the national security concerns of powerful western nations’ (324).

The chapter begins with a brief overview of the contemporary evolution of competing, and sometimes overlapping understandings of security – human, national and global – that shape the context within which health has become securitized. It moves on to sketch the various ways that health has been conceptualized as a security issue within the evolving architecture of global health governance, and uses policy responses to HIV/AIDS and contemporary influenza pandemics to illustrate how dominant understandings of global health security have been a shaping force for those policy responses. The next section raises concerns about the unfolding of contemporary practices to secure health: specifically, a shift away from a focus on the health conditions responsible for the highest levels of mortality, morbidity and human suffering in the knowledge, interventions and practices to ‘secure’ health. The conclusion identifies some of the silences and omissions that characterize the contemporary global health and security agenda.

Competing Conceptions of Security

Security is a contested term, its meaning very much dependent on the understanding of the subject or object to be secured. Realist and neo-realist theoretical perspectives have historically dominated the field of security studies, and their key assumptions have framed security’s definition. For realists, humans tend towards the atomized, rational and competitive (rather than the social and altruistic) and come together in groups out of necessity, given the need for some level of cooperation for human survival. To this end, the most important aggregate of individuals that has historically evolved to guarantee the security of the human person is the nation-state, and nationalism is the most important source of social cohesion (Wohlforth 2010, 9–10). As well, according to realists, nation-states (both the subject and object of security) exist in a world that is largely anarchic, which renders their security problematic. Because humans are largely driven by narrow self-interest, so too is the sovereign state and it follows that politics, by its very nature, is conflictual. As Wohlforth puts it: ‘The key to politics in any area is the interaction between social and material power, an interaction that unfolds in the shadow of the potential use of material power to coerce’ (10).

In a world characterized largely by anarchy, national security is primarily concerned with the survival of the sovereign state, as opposed to the individual security of its citizens, or the security of humans outside state borders. But while security is about state security, the intensification of globalization has necessitated greater levels of inter-state cooperation to mitigate new global threats, whether imagined or real.

Since the end of the Cold War, the scholarly hegemony of realist theories has been challenged on a number of levels. One of the main criticisms of political realism is its adherence to the centrality of the state in an increasingly globalized world in which borders are increasingly porous and immaterial, where extraterritorial obligations have been extended, and in which the activities in one state can have profound consequences for the security of people on the other side of the planet. Global economic integration, terrorism, more virulent pandemics and climate change, have co-evolved with a more complex regime of global governance within which increasing tensions arise between and among sovereign states. While those in positions of political power crafting security policies tend to be realists, and politics is a game of realpolitik now more than ever, the material and ideological context has shifted, and so too have the strategies. From the perspective of the advanced industrial countries, national security depends on the global expansion of western liberal values, and cooperative and ‘mutually beneficial’ forms of global governance that will address fundamental issues of ‘mutual’ concern and vulnerability. We see this, for example, reflected in the convergence in contemporary security discourses of development of both ‘soft’ and ‘hard’ security, a trend signalled by Mark Duffield in 2001 (Duffield 2001). This is apparent, for example, in a recent statement by US President Obama:

Our armed forces will always be a cornerstone of our security, but they must be complemented. Our security also depends upon diplomats who can act in every corner of the world, from grand capitals to dangerous outposts; development experts who can strengthen governance and support human dignity; and intelligence and law enforcement that can unravel plots, strengthen justice systems, and work seamlessly with other countries. (Obama 2010, ii)

A growing number of critical analysts of security both within and outside the academy (constructivists, feminists, critical theorists), although quite disparate in their approaches, share a basic understanding that what constitutes national security for any given state is subjective; it is whatever those holding power deem it to be – and, further, that it is possible to imagine a different post-Westphalian future. Critical security studies analyse the subjective nature of state security, focusing on questions of what is being secured, and for whose interests; and who is included and excluded from the realm of security (Mutimer 2010). Given that the security of all humans is deeply interconnected, it must apply to the basic security of all people. As Tickner has argued (2001, 42) the purpose of national security has rarely been to make all citizens secure, but instead to maintain the power of ruling elites, and militarization itself has become one of the greatest threats to human security, particularly of women and children. We are well aware of the human costs of national strategies to secure capital, energy, water and food, which transcend borders and can undermine the foundations of the health of distant others. While the concept of human security emerged as a critique of the hegemonic security discourse, there are many instances of its use to justify national foreign policy objectives. We see this reflected in the securitization of health.

The Shifting Discourse of Human Security

The epistemic shift in the security discourse within multi-lateral governing bodies toward human security is generally dated from the United Nations Development Programme’s (UNDP) 1994 annual Human Development Report, New Dimensions of Human Security, which focused on civilians living in conditions of poverty and marginalization. In the report the hegemonic conception of security as security of national territory from external aggression, protection of national interest in foreign policy and global security from nuclear threat was explicitly critiqued as too narrow. The report posited that human beings, not states, should be the subjects of security. It followed that genuine security of humans depended upon safety from systemic threats of physical and emotional fear, repression, violence, poverty, hunger and disease, and furthermore, that threats to security were cultural, economic and environmental as well as military in origin (UNDP 1994). Human security was largely consistent with the emergent sustainable development and human rights perspectives of the times. New global networks and allegiances that transcended the borders of nation-states advanced the understanding that national interest was inimical to human security. Throughout the 1990s the promise of a post-territorial politics emerged within the academy, civil society organizations and peoples’ movements, and some progressive pockets within the UN system. Global civil society organizations challenged the Westphalian notion of state sovereignty and the growing corporatization of the state under the neo-liberal project of the past three decades: prominent among them have been People’s Health Movement, Via Campesina, The World Social Forum, 2 and a range of indigenous, feminist and human rights movements and networks that continue to evolve. According to Brodie: ‘[T]the new common sense of who we are is increasingly visible in the explosion of civil society actors that take a borderless world as their first point of reference as well as in contemporary discourses around universal human rights and the emerging human security agenda’ (Brodie 2003, 59).

Global corporate and financial sectors, in alliance with the international financial institutions (IFIs), have also challenged the sovereignty of the nation-state, but with a different objective in mind: to secure the rights of capital against the human security and human rights claims of nation-states and global civil society movements (Bakker and Gill 2003; Harvey 2005a; Brodie 2007). Global governance has become a complex site of networks, alliances and allegiances amongst states, regional governing bodies (such as the G8 and G20), IFIs and multi-lateral organizations, global corporations and private individuals who command vast amounts of wealth and political power. Within this environment, evidence continues to mount that key political, economic and security interests have converged to strengthen the security of capital, at the cost of increased human insecurity (Bakker and Gill 2003; Brodie 2003; 2007). Nation-states are increasingly limited in their capacity to intervene in the governance of their economies and their social sectors to protect the basic human rights of their citizens. States Brodie (2003), ‘neoliberal globalization simultaneously maximizes the need for social intervention in the name of human security, while at the same time minimizes the political spaces and strategic instruments to achieve this public good’(60).

In this ideological and material context, a new health security architecture is unfolding. Lakoff and Collier identify an intensification of concern for biosecurity; referring to the new biosecurity as not only the practices associated with national security, but also the ‘… various technical and political interventions and efforts (“the forms of expertise and the knowledge practices”) to “secure health” that have been formulated in response to new or newly perceived pathogenic threats’ (2008, 8). They identify four overlapping domains of biosecurity: emerging infectious disease, bioterrorism, the cutting-edge life sciences and food safety. For Lakoff (2008) the emphasis of biosecurity intervention is emergency preparedness for diseases with the potential to threaten ‘the critical systems that underpin social and economic life’ (38). The emphasis on biosecurity has deflected political attention from other critical global health challenges, eclipsing the understanding of human health as fundamentally dependent upon the sound governance of the global life economy and people’s access to the basic constituents of health. The overarching concern with regard to ‘securing health’ has tilted toward securing the conditions for continued growth and capital accumulation.

Governance, Security and Health

Hence, we cannot separate the norms, rules and institutions through which global health is governed from the broader neo-liberal project of the past three decades. The global commitment to Primary Health Care (PHC) that emerged in the early 1970s to address the serious shortcomings of the vertical health approach that focused on technical interventions, urban hospital-based treatment, and left largely unaddressed the major determinants of poor health (Cueto 2004, 1864) exists today as little more than rhetoric. The 1978 Alma Ata Declaration codified that global commitment under the aegis of the WHO and UNICEF for an inter-sectoral and inter-disciplinary approach to health governance that included a focus on enhancing the social determinants of health and linking health with development. Criticized as being too idealistic, PHC quickly evolved into Selective PHC (Cueto 2004, 1867–68). The shift was broadly in line with the neo-liberal project and the waning power of the WHO to shape the global health agenda with the growing influence of the World Bank and other private and multi-lateral institutions.

The 1993 World Bank World Development Report, Investing in Health, articulated a global health agenda in line with the neo-liberal canon. Elements of this agenda included financing prevention and treatment for a select number of infectious diseases, increased private financing of clinical services outside a small package of essential services for the poor, the allocation of public resources according to technical efficiency and cost-effectiveness criteria and the encouragement of private suppliers for health infrastructure, medicines and human resources (World Bank 1993; Werner 1994). Kelley Lee and Hillary Goodman describe the creation of a new global epistemic community centred around the World Bank and the US Agency for International Development (USAID), consisting of a mix of public and private interests, in which economists with an overarching concern for health system financing predominated (2002, 112). WHO, the Pan-American Health Organization (PAHO), and civil society organizations were noticeably absent. The influence of private actors was increasingly secured within UN decision-making circles through private-public partnerships (Buse and Walt 2002) and today we see the rise of philanthrocapitalism 3 in the global health sector as a significant political force. The Bill & Melinda Gates Foundation, with an annual budget exceeding the core budget of the WHO, is perhaps the most powerful of a growing number of private actors shaping the global health policy agenda, who offer technocratic solutions and a particular form of neo-liberal rationality – an allegiance to market solutions as the means to tackle global health problems, top-down, vertical approaches to specific diseases and magic bullets (People’s Health Movement et al. 2008, 256).

Global health governance today is marked by a significant expansion of multilateral efforts at global health cooperation, but under the hegemony of this neo-liberal rationality. With regard to the new biosecurity, the forms of knowledge and expertise through which disease threats are understood and managed emerge from an epistemic community of individuals and organizations that are being assembled in new initiatives to link health and security – public health officials, policy experts, humanitarian activists, life scientists, multi-lateral agencies such as WHO, national health agencies such as the Centres for Disease Control (CDC), national security experts, physicians, veterinarians, and government officials (Lakoff and Collier 2008, 9). These new agents of biosecurity tend to share a technocratic, rationalistic and economistic view of health, within which emergency preparedness has become a normal feature (Lakoff and Collier 2008; Fisher and Monahan 2011). Health has come to be viewed as exemplar of humanity’s ‘new collective insecurity’ (Shaw, MacLean and Black 2006, 5). According to Pirages (2007, 625) such ‘growing complexity requires more sophisticated forms of governance’, as well as the move from a state-centric to a supranational level of global public health governance to address what are, in essence, ‘health issues that transcend national borders’. Fidler (2007) postulates that we now operate in a ‘post-securitization phase’, in which the lens of security is now an integral aspect of contemporary public health governance.

The WHO 2007 World Health Report is aptly titled A Safer Future: Global Public Health Security in the Twenty-First Century. In it, the Director General of the WHO states that ‘Shocks to health reverberate as shocks to economies and the business community in areas well beyond the affected area. Vulnerability is universal’ (2008, vi). There is much evidence in the report of the convergence of ‘soft’ and ‘hard’ discourses of security. The UN has navigated the tension between state sovereignty and multi-lateralism by unequivocally accepting the state as the global unit of analysis in terms of security (Gray 2005, 212), while drawing special attention to the obligation that states have to protect individuals’ rights to health and safety against epidemics. This is reflected in the embrace of the language of rationalist/ market values in WHO reports, alongside a stated concern for human security and the individual right to health. There is no perceived contradiction between global health security and human security; they are mutually compatible. In the words of the conclusion to the 2007 WHO report:

Although the subject of this report has taken a global approach to public health security, WHO does not neglect the fact that all individuals – women, men and children – are affected by the common threats to health. It is vital not to lose sight of the personal consequences of global health challenges. This was the inspiration that led to the ‘health for all’ commitment to primary health care in 1978. That commitment and the principles supporting it remain untarnished and as essential as ever. On that basis, primary health care and humanitarian action in times of crisis – two means to ensure health security at individual and community levels – will be discussed at length in The World Health Report 2008.

The 2008 report, Primary Health Care: Now More than Ever, was published on the 30-year anniversary of Alma Ata and documents some of the shortcomings of contemporary health systems, among them the disproportionate focus on hospital care, fragmentation of health services, and the proliferation of unregulated commercial care. It admits that global health gains have been ‘unevenly shared’ particularly on the African continent where health has stagnated or worsened (WHO 2008). The report is largely silent on the global political and financial context of health policy reform. The WHO has become particularly vulnerable to donor interference from both member states and private powers as the proportion of its expenditures supported by extra-budgetary funds (EBFs) – grants or gifts often tied to specific interests or projects – rose from 20 per cent in 1970 to about 75 per cent in 2007, with the Gates Foundation alone contributing USD99.4 million in 2006, tied for 3rd with Japan: ‘What is striking about the budget for 2008/9 … is the reliance on EBFs and the high allocations to communicable disease relative to food and nutrition; non-communicable disease; social and economic determinants of health; and environmental health’(People’s Health Movement et al. 2008, 225–9). An open letter drafted by the People’s Health Movement to the delegates of the 64th World Health Assembly, held in May 2011, points to the powerful interests that are pressuring WHO into a restricted technocratic role on communicable disease control and ‘health security’, distanced from critical determinants of health, such as economic development, justice and peace:

… It is essential that the reform of WHO be framed around the health needs of people instead of being centred upon the financial crisis. Health policy making over the last 30 years has been distorted by the pressure of odious debt, the defence of intellectual property and the rationalization of an unjust economy. WHO should speak truth to power. 4

There is much to suggest that PHC and the social determinants of health will continue to take a back seat to the biosecurity concerns of the major industrial powers within the global health governance agenda. John Kirton and Jenevieve Mannell (2007) observe that rising panic over HIV/AIDS and the threat that it posed to the US and Europe first drove the G8’s concern, followed by SARS, bioterrorism and avian influenza. Global health, narrowly defined, was added as a main agenda item at the G8 annual summits, with annual Ministerial meetings since 1999 on health security and bioterrorism. They argue that ‘[S]ince the onset of rapid globalization in 1996, the G8 has emerged through several stages as an effective, high performing centre of global health governance across the board’ (Kirton and Mannell 2007, 133). But for whom was the G8 high performing? Here we can begin to see the tensions between biosecurity practices and human security, in the governance of the socioeconomic and geopolitical aspects of neo-liberal globalization. The socioeconomic and environmental impacts of neo-liberal globalization create new health challenges that threaten human security. The concerns that predominate with regard to health security focus on securing populations and economies from a range of microbial threats that could potentially contaminate food supplies, undermine growth and productivity, overwhelm public health systems and, theoretically, challenge the stability of nation-states. Meanwhile, structural influences on trans-border threats to health – climate change, the consolidation of the global industrial food industry, the ‘meatification’ of global diets, de-peasantization and the movement of populations into sprawling, unhygienic global slums – have become more pronounced during the last three decades of globalization. Some of these tensions can be illuminated through an examination of the sets of knowledge about, and policy responses to, contemporary health ‘emergencies’ that have been specifically constructed as threats to health security: HIV/AIDS and the new influenzas. In Labonté and Gagnon’s 2010 examination of major English language health and foreign policy statements, issued from the early 2000s until 2009, fear of disease pandemics turned up most frequently as a security concern (2010). There are other examples, but it is to these two that this chapter now turns.

HIV/AIDS: The 'Slow Motion' Pandemic

HIV was one of the first pathogens to be constructed as a security issue. In 1990, the US Central Intelligence Agency (CIA) added HIV/AIDS as a variable that might cause greater state fragility and eventual failure, particularly in the developing world (Fourie and Schönteich 2002, 8). The formal securitization of AIDS followed a visit by the US ambassador to the United Nations, Richard Holbrooke, to Africa in December 1999 to witness the impact of the growing AIDS epidemic. On 10 January 2000, the UN Security Council (UNSC) for the first time in its history debated a health issue in terms of security (Behrman 2004, 158–65). This meeting was followed in July 2000 by UN Resolution 1308, which formalized the securitization of HIV/AIDS by referring to it explicitly as a national security crisis. 5 However, the language of human security was also evoked in Resolution 1308, and the Joint United Nations Programme on HIV/AIDS (UNAIDS) was charged with the main responsibility to respond to this challenge. In 2001, Mark Duffield illuminated the manner through which ‘development’ and ‘security’ were converging into a new security framework characterized by a blurring of the boundaries between ‘soft’ and ‘hard’ security concerns, and by an erasure of historical inequalities within the global system (Duffield 2001). One year after Resolution 1308, in mid-2001, the UN General Assembly held a special session on HIV/AIDS (UNGASS), which went even further in placing the pandemic on the multi-lateral agenda. During the special session, former US Military Chief of Staff and then Secretary of State General Colin Powell (2001) declared: ‘It not only kills. It also destroys communities. It decimates countries. It destabilizes regions. It can consume continents. No war on the face of the earth is more destructive than the AIDS pandemic.’

In May 2002, the Clinton Administration designated the spread of AIDS around the world as a threat to its national security. It is not clear how widely these views were shared by other advanced industrial nations, but it appears that the security prism became a central justification for the Bush administration’s ramping up its response to HIV/AIDS in Africa. The July 2007 issue of Vanity Fair, guest edited by Bono, had this to say: ‘We at Vanity Fair didn’t think there could be a silver lining to the Bush administration, but perhaps, it is, of all things, President George W. Bush’s work for Africa. As the OECD … reports, the U.S. has quadrupled aid to the continent over the last six years. In his 2003 State of the Union address, Bush pledged $15 billion to fight AIDS primarily in Africa …’ (Robinson 2007, 52). 6

With sub-Saharan Africa as the focus, the security polemic focused on a number of interrelated threats emerging from HIV morbidity and mortality: the potential negative impacts of deaths of adults in the peak of their productivity on the health of the public and private sectors, on governance and on economic growth; the consequences of HIV infection amongst migrant labourers, soldiers and peace keepers as vectors of infection and drivers of violence; low intensity war and HIV spread; synergies between rural HIV morbidity and mortality and food security, and broader geostrategic ‘threats’ resulting from high levels of HIV in already unstable parts of the global south (Ostergard 2004 Fourie 2007; Elbe 2009). According to Fourie (2007, 284) the central polemic with regard to state collapse in Africa was based upon rather ‘loose and unsubstantiated statements about the covariance of mature AIDS epidemics on the one hand, and state fragility on the other. In other words, there is an assumption that state fragility in itself relates an enabling environment for the vectoring of HIV. Rising prevalence levels in turn are seen to be contributing to state fragility and ultimate state collapse’. Fourie argued that the ideological prescriptions emerging from this model formed the basis of a multi-lateral consensus for ‘“good AIDS governance” with … exceedingly political implications for the purported links between HIV and democracy, democratic remedies/vaccines against HIV, the inferred links between HIV and fragile states …’ (2007, 2877). The link between AIDS and state failure could ostensibly be used as a justification for interventions targeted at specific states and sectors of national interest, and people whose lives are deemed more valuable than others.

Alan Ingram’s (2007) case study of US responses to HIV/AIDS in Nigeria illustrates this point. Significant US support for HIV/AIDS prevention and treatment flowed to the Nigerian state because of its importance to US energy security and counter-terrorism in the trans-Saharan region; Nigeria was also considered a key location in the next wave of the pandemic. Ingram analysed the policy documents of a number of private and public institutions engaged in the policy response to HIV/ AIDS in Nigeria, including American corporations with oil interests in the region and different branches of the US military, and found that they ‘extensively use the new security discourse in the direct service of hegemonic strategy, positing a seamless (though scarcely plausible) continuum between a wide range of concerns: human rights, humanitarianism; governance; counter-terrorism; incorporation into the global economic order; and the vital security of the great powers’ (Ingram 2007, 521). The extent to which national security issues have driven the targeting of AIDS funding toward military related initiatives in regions where donor countries have specific economic or geopolitical interests is hard to discern; however, whether imagined or real, the focus on security may well have deflected attention from other countries or sectors where the ‘risks’ posed by HIV to human security were potentially greater. Similarly, the discursive framing of HIV/AIDS as a threat to national economies has justified a focus on interventions to secure the health of very specific labouring populations. When Anglo Gold in South Africa reported in 2002 that between 25 and 30 per cent of its entire southern African workforce was HIV positive, ARV treatment was provided to its employees to mitigate the impacts on the company’s profitability and future expansion (Plumley et al. 2002). The epidemic became a core business issue and other companies followed, including Anglo Coal, Coca-Cola and Eskom. The explicit motive of the business sector was to address and safeguard central business activities through extending prevention and treatment programmes to their own workforces. It was after Coca-Cola was criticized for providing drugs only to its more valuable white-collar workers that HIV/AIDS interventions were extended to its blue-collar workforce and broader communities. As the private sector took on a more active role, public-private partnerships (PPPs) and increased philanthropy reflected the assumption of a ‘common purpose and agenda’ of business and society (Daly 2000, 31), despite evidence of burden-shifting practices in Zimbabwe, Nigeria, Botswana and South Africa such as pre-employment HIV screening, reduced employee benefits, outsourcing of low-skilled labour and the substitution of capital for labour (Rosen and Simon 2003).

Throughout the 2000s, the emergence of PPPs between the major pharmaceutical companies producing antiretrovirals and the UN, pharmaceutical industry pilot programmes and partnerships between private industry, NGOs and foundations such as Gates and Clinton had an impact on the direction of policies to address the multiple impacts of the pandemic. To give an example, the joint pharmaceutical industry/UNAIDS Accelerated Access Initiative, formed in 2000, was designed to scale up treatment in developing countries, in line with the protection of IP rights and without questioning their role in preventing access (UNAIDS 2000). Part and parcel of such programmes was the provision of cost-effective doses of ARVs to prevent mother-to-child transmission; for years there was a remarkable silence about the ethics of a programme that saved babies while leaving mothers to die, leaving aside the question of who was to care for the orphaned children. There was also a silence around the risk to women of a single, cost-effective dose of nevirapine for developing resistance to this family of ARVs. A hierarchy in the value of human life was implicit in this particular aspect of the response, both between and within countries; at the top, affluent, largely white people for whom HIV infection was understood as a chronic disease; at the bottom, the most marginalized people living outside market relations, whose deaths would have little (measurable) impact on economic growth and state stability. Hence, the presumed disposability of poor mothers in the non-waged and informal sectors, despite their critical role in providing household security through their caring, subsistence and informal labour. Treatment for women has expanded with the general scaling-up of ARV treatment, but provision remains highly unequal, as do the capacities and competencies to improve access. The almost single-minded focus on ARV scale-up has deflected attention away from the complex socioeconomic and political drivers, as well as unequal gender relations and violence, that continue to shape risk and resilience in specific communities (O’Manique 2009). The subtle convergence of ‘human security’ and ‘economic security’ concerns in the discursive construction of the policies and practices within the ‘business response’ masks the pre-eminence of corporate over human security concerns.

For proponents of the securitization of AIDS it may indeed have achieved what many had hoped: a sense of urgency, and increased funding (particularly of PEPFAR) and position on the political agendas of individual states as well as of multi-lateral organizations. But predictions of state fragility and economic collapse have not been borne out; in fact, countries with mature epidemics – Uganda, Tanzania, South Africa – have maintained steady levels of growth, while addressing the human security impacts of the pandemic in the poorest households has remained marginal in policy responses: the loss of family members, and hence their labour; the systemic increase in inequalities particularly between men and women, given women’s central role in the economy of care; and the collapse of the poorest households. Household collapse has manifested through proxy crises – famine and malnutrition, drug-resistant tuberculosis (which piggy-backs on HIV infection), poor subsistence production, the liquidation of assets to pay for medicines and funerals. As de Waal (2003, 3) states: ‘Rather, like the effect of HIV on the human body, an “AIDS related national crisis” will consist of a range of pre-existing social and political pathologies, rendered more common and more severe by the underlying vulnerability caused by resource losses due to AIDS.’ The long-wave nature of the virus has meant that societies have adapted to a ‘new normal’ that includes HIV as well as other forms of structural violence. Rather than advancing the human security agenda, the security polemic of HIV/AIDS has tended to be framed within a traditional paradigm that privileges military and economic interests, discursively aligning these with liberal, developmental concerns. The national emergency frame justifies policies that are targeted at key sectors of the economy, have immediate impact and categorize saving (certain) lives as counting deliverables. The construction of HIV/AIDS within this emergency frame rather than the longer term – in fact, according to Barnett (2006, 204) it is a slow-motion lentivirus that might take up to 130 years to play itself out – also deflects attention from social transformations resulting from significant changes in the population structures of many African societies, while another concern that has been raised is the counter-productive effect of ‘othering’ and stigmatizing selective aspects of epidemics and constructing certain individuals as vectors, who are then seen as the enemy (Elbe 2006; Sontag 2002). In the early years of the AIDS pandemic, homosexuals, intravenous drug users and sex workers were seen as the carriers of a condition that they had brought on themselves, exacerbating the criminalization of individuals, rather than eliciting a response driven by the imperative to make specific communities less vulnerable to infection. The worst impacts of HIV are experienced in contexts of intensified poverty, where health systems are weak, and where there is a scarcity of other basic needs such as access to nutritious food, rest and social supports. Both gendered and the structural analysis of the spread and impacts of HIV are hidden or obscured in the security discourse (O’Manique 2006; Tiessen 2006; Ingram 2007). The crisis of care at the household level, which is experienced largely by women who shoulder the main care burdens, receives little meaningful attention. While some observers, such as Colin McInnes and Simon Rushton, note that the securitization of AIDS has been overstated and that it has been only one of the motivations for the proliferation of global initiatives (2010, 232), one could argue that its greater impact has been discursive and/or ideological.

The 'New' Influenzas

In contrast to HIV/AIDS, the impacts of the recent influenzas can be distinguished by the potential ease and speed with which they spread from human to human and their immediate impacts, perceived or otherwise. Pandemic preparedness has become a key focus of biosecurity, and is driven by a number of factors. Over the past century, there has been a steady increase in the number of reports of novel sub-types of influenza in both humans and animal and bird species, with experts predicting that it is only a matter of time before the world experiences a more deadly influenza pandemic with potentially devastating short- to long-term consequences. Debrix and Barder describe the climate of fear during the 2009 swine flu epidemic in which people came to fear not so much the disease, but the terror that the disease had come to represent. In this heightened economy of fear, citizens demand protection, and governments have little choice but to respond. In this way, new biological threats have become the objects ‘of sustained normalization or heightened regulation’ (Debrix and Barder 2009, 401).

The current epidemiologic transition of newly emerging, or re-emerging pathogens is conditioned by accelerated globalization processes. Air travel means that lethal viruses can quickly be transported from one corner of the world to another (Grais et al. 2003). Davis (2005) describes the co-factors that shaped the 2003–2004 avian influenza threat, the H5N1 strain that caused viral panic. The incubator for a potential ‘viral apocalypse’ was the growth of mammoth industrial poultry factories operating in close proximity to increasingly densely populated human settlements where chickens and ducks freely co-mingled with humans. The worry about the H5N1 strain of avian influenza was that it could potentially develop into a lethal pandemic strain through genetic re-assortment – the mixing of genetic material from an avian and human flu virus during a co-infection. Confirmed individual cases of avian influenza in southeast Asia had a history of direct contact with poultry. But global panic was driven by the prospect of a viral mutation setting off an explosion of human-to-human transmission which in fact, could have had quite significant global consequences.

The underlying forces identified by anthropologist Komatra Chuengsatiansup (2008) that were at work in the response of the government of Thailand, one of the countries at the epicentre of the epidemic, were largely sociopolitical in nature. He describes a situation in which, for months, state officials denied the presence of a bird flu epidemic despite the fact that massive numbers of chickens were dying. At the time of the 2003 outbreak, the son-in-law of the owner of a Bangkok-based agricultural-export conglomerate and largest producer of poultry was sitting in the cabinet. Media reports at the time alleged that the non-response of the government gave the largest agri-business exporters ample time to process and sell their inventory, and to disinfect their plants. When new cases and fatalities occurred into the next year, 60 million free-range chickens and ducks were ordered slaughtered in Thailand, most belonging to small farmers whose basic livelihoods depended upon them. States Chuengsatiansup: ‘While the epidemic caused devastating damage to small farmers, it created a unique opportunity for big agri-business to re-structure the nation’s poultry industry’ (2008, 55–6). While migrating birds were posited as the primary vector for bird flu, the etiology of avian influenza was more likely located in the international mass movements of birds and bird products from factories that have made the chicken the most mobile bird on the planet (Bingham and Hinchcliffe 2008, 188).

Interventions, then, principally focused on mitigating the potential impact of the epidemic on sociopolitical stability. Global pandemic preparedness has been a central feature of the convergence of security agendas with global health, and significant investments have been made to prepare for emergencies: to improve surveillance and outbreak investigation, strengthen laboratory systems and treatment, prevent spread, develop capacity for risk communication and public education, develop and administer vaccines, and stockpile anti-virals. 7 This ramping up has been, and will continue to be, highly uneven and shaped by vested interests (including the pharmaceutical giants), 8 with western countries focusing on their own pandemic preparedness while the UN system copes with the coordination of the global health security architecture in poor countries (White and Banda 2009). The institutional weakness of the UN system vis-à-vis nation-states and the IFIs, its lack of autonomy, and its limited budget, will likely constrain the ability of the WHO to mount a truly global response against the more powerful nation-states who are concerned first and foremost with their own populations and ‘national interests.’

Global governance is failing the real test of ‘global solutions’ based on the ostensible concern that we are all equally vulnerable. Ferguson postulates that a virus similar to the one that caused the 1918 pandemic would likely have a global death toll of 62 million, with only 4 per cent of those deaths in the industrialized world (2006, 2187–8). The global geography of mortality and morbidity is shaped by highly uneven supplies and quality of vaccines, limited anti-viral access and desperate living conditions in mega-slums which face challenges of overcrowding and lack of basic hygiene (Davis 2005). Even if a global stockpile of antivirals were created, it is not clear how and under what conditions it would be deployed. Claims of inter-dependence and myths of mutual vulnerability that have accompanied the threats of SARS and avian influenza have not led to significant attention to pandemic preparedness in the global south. A 2010 report on H1N1 influenza in LDCs in sub-Saharan Africa stated that surveillance was virtually non-existent and not sufficiently sensitive to pick up clusters of viral infection – a critical early warning system that a virus is improving its transmissibility. Confirmation of influenza is technically challenging and expensive, infection control difficult to introduce and sustain and high prevalences of co-morbidities (TB, immunosuppression and untreated HIV and STDs, as well as generalized poverty places sub-Saharan African countries at heightened risk of a more virulent pandemic (HPA Global Health, 2010). There is little incentive to comply when the obligation of poor countries to report suspicious clusters of novel diseases might lead to unpopular actions such as the massive culling of smallholder livestock, border closings and quarantine, and when there is little evidence to suggest that the first affected countries would be assisted by the international community. Nor is there incentive if the profitability of the largest industries could be threatened by compliance. Today, as Labonté and Gagnon point out, most health aid focuses on particular disease programmes, while very little is targeted at the public health interventions that reduced communicable diseases in the nineteenth century, such as sanitation, potable water, slum upgrading and disease surveillance and monitoring (2010, 8).

It is likely that the conditions that have created more virulent pathogens, such as the intensification of poultry and/or livestock production within the global agroindustrial food chain, will continue, unabated. The impact of the global financial crisis that began in 2008 will likely further undermine public health in different parts of the world. Gaping holes remain in the most basic health coverage and epidemiological surveillance in places already coping with a wide range of infectious and chronic diseases. Healthcare systems, already fragile and overburdened by the demands of HIV/AIDS, tuberculosis, malaria and other diseases, will become more compromised with the emergence of new influenzas. Estimates now place the number of people on the planet suffering from malnutrition at one billion, a figure likely to grow with the diversion of arable land to the production of bio-fuels, land-grabbing and speculation in agricultural commodities (Patel 2011). Chronic disease, malnutrition, overcrowding, sub-standard water and sanitation, combined with the fragile state of public health systems and access to basic medicines, constitute the elements of the current global health apartheid that will shape risk and resilience in the future.

Human Security and the Limits of Biosecurity

A holistic understanding of the multi-dimensional nature of the factors that shape human health – clean water and air, healthy food, physical security and warmth, bodily autonomy and integrity, rest and leisure, access to health information, health care and medicines – continues to evolve, but has had only a minimal influence on health policy perspectives and practices. Human health is entwined with the conditions and contexts within which our lives unfold. Hierarchies of class, gender and ethnicity that shape communities and the physical environments in which we live are imprinted on the body. The current governance of the global economy that privileges the security of capital at the expense of human security (Brodie 2003) has a profound effect on global patterns of disease and individual risk and resilience. Today’s health and security agenda ignores the human security crisis of health: the boring, persistent, communicable and non-communicable diseases that in fact kill more people annually world- wide than high-profile diseases such as HIV-AIDS. It also leaves untouched the roots of the contemporary ‘threats’ that have been the focus of biosecurity.

Multiple, reinforcing crises that affect access to health services and medicines and social determinants of health are shaping the global pattern of disease distribution. But the problem goes beyond this to include threats to local ecologies upon which animal, human and plant populations depend. These threats emerge from the interconnected processes of wealth and income polarization and the rise of private power, species extinction, deforestation, land degradation, pollution and climate change. Food insecurity is on the rise, a consequence of the articulation of a range of local and global forces which leads to speculation on food commodity markets and drives up prices; free trade agreements that have undermined local food markets and have led to the global consolidation of agro-industrial economies; and human-induced climate change (Patel 2007, 2011) Those at greatest risk are the most vulnerable communities that depend directly on their local ecosystems for their survival. The twin pandemics of malnutrition and obesity (Patel 2007) are driven by the privatization and consolidation of the agro-industrial model that also produces the new ‘threats’ of more lethal viruses and food-borne pathogens. These are the same forces that produce the neo-feudal conditions of production in the factories and plantations of the global south that undermine both mental and physical health for hundreds of millions of workers. Zacher and Keefe (2008, 9) point out that 30 per cent of people living in the global south die of infectious disease; the figure is 50 per cent in the case of sub-Saharan Africa, compared to one per cent in the global north. Other chronic, persistent, stubborn, mundane and, in many cases, highly treatable diseases responsible for hundreds of thousands of deaths receive remarkably little attention. We must also consider and account for the huge costs caused by the diversion of labour to care for the sick, and costs to local productivity as well as quality of life.

Although the pathways between particular threats and specific features of globalization are increasingly understood in the emergent health and security agenda, the policy response takes as a given that market-driven globalization, on the whole, is not a threat to human health. As Labonté and Gagnon argue, securitization of health ‘remains premised in a conception of the individual made capable to function as a market actor; that is, it supports, rather than challenges, the social and economic assumptions that have driven the past three decades of neoliberal globalization’ (15). A human security lens can help to demystify the pathologies embedded in the current governance of health. The larger and more pressing challenge lies in the broader political project of exposing and addressing the remarkable silences about these pathologies in the current policies and practices not only of global health governance, but in the current governance of the global economy that increasingly privileges the ‘rights’ of the owners of capital, over rights of human beings (and we could include other species) to the most basic constituents of life. Properly framed, a human security perspective asks the basic questions: Governance for whom? Who lives, and who dies? And who decides?

‘Freedom from want’ was enshrined in the Universal Declaration of Human Rights in 1948, and is understood broadly to mean freedom of deprivation from basic human needs. The specifics are codified in Article 25 of the UDHR: ‘Everyone has the right to a standard of living adequate for the health and well-being of his family [sic], including food, clothing, housing, and medical care, and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age, or lack of livelihood in circumstances beyond his control.’ See:

The growth and reach of trans-national civil society organizations, networks and movements has been facilitated by the expanding reach of information technologies. The People’s Health Movement (, Via Campesina ( and the World Social Forum ( all share an alternative vision of globalization broadly compatible with the concept of human security.

‘Philanthrocapitalism’ is a term used by Matthew Bishop and Michael Green to distinguish the ‘new’ philanthropists such as Warren Buffett and Bill Gates who command billions of dollars, and who, in their view, are improving philanthropy through applying the ‘secrets’ behind their money making success to their philanthropy. See Bishop and Green (2008, 3).

This is an open letter on the website of the People’s Health Movement: ‘Comments on the future financing of the WHO’, available at: [accessed: 5 May 2011].

The full text of the resolution is available at: [accessed: 5 May 2011].

The theme of this particular issue of Vanity Fair, guest edited by philanthrocapitalist Bono, was the re-branding of ‘Africa’ in line with the shift toward market solutions for global health emergencies. Bono’s Product (RED) was featured as a viable solution to the HIV/ AIDS crisis in ‘Africa’.

The Global Alert and Response (GAR) site on WHO pandemic influenza preparedness is available at: [accessed: 1 June 2011].

A 2011 Canadian Broadcasting Corporation (CBC) investigation revealed that three of Canada’s most prominent flu experts had received research funding from the makers of the anti-viral Tamiflu, the front-line defence in the 2009 outbreak. Over the past decade Hoffman-La Roche Ltd sold about USD10 billion worth of the drug globally. Half of the USD180 million stockpiled by the Canadian government is about to expire, while controversy over both its efficacy and possible side-effects continue.

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