The Chronicle of a Disease Foretold: Pandemic H1N1 and the Construction of a Global Health Security Threat

Abstract

The period beginning in 2004 saw an extraordinary spurt in attention paid to avian and pandemic influenza in the United States and at the global level. A disease that for decades had languished in the ‘dull but worthy’ category of infectious diseases was elevated to a risk to global health security. The securitisation of influenza was not unproblematic. The influenza pandemic of 2009 turned out to be far milder than anticipated, and much of the scientific basis on which planning had proceeded and resources had been mobilised turned out to be wrong. Developing countries with other disease priorities were urged to pour resources into pandemic planning exercises and change poultry-raising practices. The article argues that for an issue to be securitised as a global health threat, it is essential that the United States takes the lead role (or at the very least supports efforts by other leading powers). It uses the Copenhagen School's analysis to examine how avian and pandemic influenza was securitised in the United States, and then uses the concept of framing to examine why this disease was securitised by looking at the prior existence of an issue culture or discourse around emerging infectious diseases, which gained salience after the 2011 anthrax attacks. It finally looks at the impact of securitisation on countries with different priorities.

Keywords

pandemic influenza securitisation global health security framing

The influenza pandemic of 2009 was an event the world had begun preparing for at least five years before it happened. As Margaret Chan, the World Health Organization's Director-General, told a meeting of ASEAN health ministers shortly after the new pandemic virus appeared, ‘The world is better prepared for an influenza pandemic than at any time in history’ (Chan, 2009).

The period beginning in 2004 saw an extraordinary spurt in attention paid to pandemic influenza in the United States and other leading countries, as well as at the global level. The Bush administration had declared pandemic influenza ‘a danger to our homeland’ and the US Congress had authorised over US$6 billion in spending on pandemic preparedness, compared to the US$50–100 million that had been authorised in previous years for flu-related spending (Lister, 2007). At a global level over US$2 billion had been pledged by the world's wealthier countries to help poorer countries prepare for a pandemic (UNSIC, 2009). Elaborate preparedness plans were created, antivirals were stockpiled, and prototype vaccines had been developed for a possible pandemic.

This attention to flu was an extraordinary development. For decades influenza had occupied the ‘dull but worthy’ category of infectious diseases. It had neither the global impact that diseases like HIV/AIDS, malaria and tuberculosis had, nor did it extract the toll on life that coronary heart disease and other major non-communicable diseases did. Although flu experts spoke of the danger of new pandemic viruses emerging that could cause significant illness and death at the global level, and harked back to the millions of lives that had been lost in the 1918 pandemic, more recent pandemics in 1957 and 1968 had taken a relatively low toll, and the danger of a pandemic was not something that occupied either government or public attention.

This article argues that the intense global attention paid to influenza was only possible because the disease was securitised and constructed as a threat to global health security. It argues that the United States for a variety of reasons felt at heightened risk from a pandemic, and with the help of its allies mobilised the global community to respond to this risk by securitising pandemic influenza and lifting it from the arena of public health, to what David Fidler (2003) has described as the ‘high politics' of national and global security. This global mobilisation through securitisation was necessary because it was thought that the pandemic would emerge from elsewhere in the world, probably South-East Asia, and then threaten the United States and the rest of the world. Preventing or mitigating the impact of a pandemic in the United States therefore required global action.

This securitisation ensured global action, but it was not unproblematic. The pandemic that emerged in 2009 was different in every possible respect from the pandemic that had been predicted by scientists and public health experts. The scientific and technical basis on which pandemic planning had proceeded, and on which time and resources had been lavished, turned out to be wrong. The pandemic did not originate from an H5N1 virus as had been expected, but from a previously unknown swine origin virus. It began not in Asia, where great resources had been devoted to pandemic surveillance, but in North America, which was considered to be the last place a pandemic might originate. The illness and mortality from a flu pandemic had been predicted to range from around 2 million to over 100 million. In fact, the toll taken by the 2009 pandemic was estimated to be less than that of the normal seasonal influenza. In all, the pandemic of 2009 was clearly not a threat to global health security under any definition of security.

It can be argued that scientific risk assessments always carry a measure of uncertainty and the facts on the ground still warranted action on the basis of the precautionary principle. However, the purpose of this article is not to examine the quality of pandemic risk assessment from a scientific or technical perspective. Rather, it is to understand the process by which influenza was securitised, and to draw some conclusions about how diseases become securitised at the global level, and which actors and audiences need to be involved in this process.

The Copenhagen School's analytical framework, more fully described in the section below, is used to understand the processes by which pandemic influenza was securitised. This study also tries to take the analysis one step further by looking at the factors that created a heightened risk perception in the United States, which helped audience acceptance of securitisation. To look at these perceptual factors, this study uses the concept of framing to explain the conditions that gave rise to a powerful and influential discourse around emerging infectious diseases that preceded securitisation. It was the prior presence of such a discourse which created risk perceptions that made securitisation credible and possible. Finally, the article looks at the impact this securitisation had on countries that did not share the same perception of existential threat from pandemic influenza.

Securitisation as a Framework for Analysis

The article follows the Copenhagen School in using the concept of securitisation as the organising principle for this study (Buzan et al., 1998; Waever, 2004). This concept is used because only a constructionist approach can uncover the complex interactions between the natural world, where new viruses and pathogens emerge, and the social world, which responds and reacts to them. The elevation of pandemic influenza was not a straightforward response to developments in the natural world, but was mediated and socially constructed by actors and institutions. As Ole Waever describes it, ‘the task is not to assess some objective threats that “really” endanger some object, rather it is to understand the processes of constructing a shared understanding of what is to be considered and collectively responded to as a threat’ (Waever, 2004, p. 3).

The Copenhagen School sees securitisation as a subjective process in which a credible actor or actors describe an existential threat, audiences accept this explanation, and measures outside the scope of normal politics are taken to meet this threat. As Barry Buzan et al. describe it, a key element is ‘the designation of an existential threat, requiring emergency action or special measures and the acceptance of that designation by a significant audience’ (Buzan et al., 1998, p. 27). Summarised by Colin McInnes, three facilitating conditions are required for successful securitisation: it must follow the accepted grammar of security; it must come from an actor in a position of authority to pronounce on security; and it helps (but may not be necessary) if the object can generally be held to be threatening (McInnes, 2004, p. 51).

Based on this, who were the actors, audiences and speech acts involved in securitisation, and what were the special or extraordinary measures taken that would indicate securitisation? In terms of actors, if a threat is to be securitised at the global level, it is reasonable to state that United States involvement, either in the form of initiating the securitisation, or actively supporting the actors involved in securitisation, is essential. It is difficult to conceive of an existential threat perceived by countries like China, India, Brazil or Nigeria being securitised at the global level unless the United States actively backs and supports this. Even a threat that the European Union, or Japan, perceives, is not likely to be discerned as a global threat without the backing of the United States. Despite the erosion in its relative power, the United States, either alone, or with the backing of its allies, still has the power to securitise issues through its global standing and its influence in global institutions and organisations such as the United Nations and the World Bank.

The Securitisation of Pandemic Influenza

In the Copenhagen School's analysis, a speech act is the moment that securitisation occurs. As Waever puts it, ‘It is by labelling something a security issue that it becomes one’ (Waever,

2004, p. 8). Two speeches by US President George W. Bush in 2005, one at the US National Institutes of Health (NIH), and the other to international leaders at the UN General Assembly, helped to securitise pandemic influenza at the national and global levels. In his speech to the NIH in November 2005, Bush warned of the ‘danger to our homeland’ posed by avian and pandemic influenza, and outlined a raft of domestic and foreign policy measures including a National Bio-surveillance Initiative and an International Partnership on Avian and Pandemic Influenza (IPAPI), designed to create ‘a global network of surveillance and preparedness that will help us to detect and respond quickly to any outbreaks of disease’ (Bush, 2005b). The speech described avian and pandemic flu as a threat to the nation, and included a US$7 billion request to Congress for emergency funding for pandemic preparedness: ‘By preparing now, we can give our citizens some peace of mind knowing that our nation is ready to act at the first sign of danger’ (Bush, 2005b). Bush's speech made it clear that this was an issue that needed to be securitised at the global level: ‘a flu pandemic would have global consequences, so no nation can afford to ignore this threat, and every nation has responsibilities to detect and stop its spread’. Earlier, addressing the UN General Assembly in September 2005, Bush once again spoke of the global socio-economic and security consequences of an influenza pandemic and announced US global leadership to contain this threat through the IPAPI (Bush, 2005a).

Securitisation requires extraordinary measures to be taken to respond to an existential threat. Bush's speech made clear that the threat was existential – ‘a danger to the homeland’. It also set out actions beyond the scope of usual public health. The measures that were proposed to respond to the pandemic were similar to the response to a terrorist attack, or any other national emergency. Homeland Security Presidential Directive 5, one of the many executive orders that were passed after the 9/11 attacks to respond to terrorist attacks and other emergencies, was used as the template to respond to a possible pandemic (Homeland Security Council, 2006). The Secretary for Homeland Security was given the responsibility for coordinating the overall US federal government response to the pandemic, while the Secretary for Health and Human Services focused on the medical response. Pandemic influenza had been taken beyond the realm of public health into the realm of national security, a point that an American Civil Liberties Union report noted: ‘Rather than focusing on well-established measures for protecting the lives and health of Americans, policymakers have recently embraced an approach that views public health policy through the prism of national security and law enforcement’ (Annas et al., 2008, p. 5).

The speeches by Bush were followed by an intense US diplomatic effort to raise avian and pandemic influenza to the status of a major global threat. Bush stressed the importance of the issue in meetings with the presidents of China, Indonesia and Russia and the prime minister of Thailand, as well as at an APEC summit in 2005 (Dobriansky, 2005). The State Department was tasked with coordinating the global response to a possible pandemic through IPAPI, and over US$900 million was pledged to over 100 countries for pandemic preparedness, surveillance and response. The Department of Defense, through its Global Emerging Infections Surveillance and Response (GEIS) programme and its overseas labs in Indonesia, Egypt, Kenya, Peru and Thailand, was involved in surveillance, research and response to the pandemic, as were the US CDC (Centers for Diseases Control and Prevention) and USAID (Salaam-Blyther and Chanlett-Avery, 2006).

IPAPI was an important mechanism for expanding the securitisation of pandemic influenza at the global level. Under US leadership, a series of ministerial meetings was held (in Washington in 2005, Beijing, Vienna and Bamako in 2006, New Delhi in 2007 and Sharm el-Sheikh in 2008) to raise funds and focus the attention of governments on the threats posed by avian and pandemic influenza. These meetings brought together the majority of the world's states and intergovernmental organisations (there were 120 countries and 26 regional and international organisations represented at the Sharm el-Sheikh meeting), and their frequency (six over three years) was unprecedented for a health issue.

The IPAPI ministerial meetings showed that pandemic influenza had been raised to the level of a disease that required urgent international action because of the threat it posed to global society. The speeches and declarations made at these meetings also left little doubt that avian and pandemic influenza posed a security threat. The declaration at the end of the Beijing IPAPI ministerial meeting stated that ‘a pandemic could potentially kill millions and cause catastrophic consequences in the areas of global economic growth, trade, and security’ (Beijing Declaration, 2006, emphasis added).

The US role in securitising influenza was also implemented through the United Nations and the World Health Organization (WHO), and other members of the UN family such as UNICEF and the Food and Agriculture Organization (FAO). The US is the largest single contributor to the finances of the UN organisations, and if the US decides that an issue is a priority, it has the clout to ensure that that the UN family takes it seriously.

The United Nations was mobilised to help countries face this new threat, and among other things put in place a coordination system to mobilise resources and help countries respond to a pandemic, headed by David Nabarro, a senior WHO official. From the language used by senior officials, there was little doubt that a pandemic could pose an existential threat to individual countries and global society. The UN Secretary-General, Kofi Annan, described it as a ‘grave threat’ that could bring ‘terrible consequences' to the world (Annan, 2006). At a press conference in New York, shortly after his appointment as the senior UN coordinator for avian and pandemic influenza, Nabarro suggested that the death toll from a pandemic could range between 5 million and 150 million, a figure that implied a major threat to global society (Ress, 2005).

At the WHO, there was a spurt of activity in creating pandemic preparedness plans, mobilising resources and creating technical guidelines for countries to follow for surveillance and response to a pandemic. The inclusion of novel human influenza viruses as one of four diseases under the revised International Health Regulations (IHR) (along with smallpox, poliomyelitis and SARS) that countries were automatically required to report to the WHO was a significant indication of the securitisation of pandemic influenza at the global level (WHO, 2005).

The member states of the United Nations accepted this securitisation; there were no protests either in General Assembly debates, or at the World Health Assembly (the annual gathering of WHO member states) about the prioritisation given to pandemic influenza and the extraordinary measures that were being taken to meet this threat. However, this did not mean that securitisation was uniformly welcomed, or that all countries felt equally threatened by avian and pandemic influenza. An important focus of US diplomacy as well as the UN organisations was to try and persuade countries to raise their perceptions of this threat. Among IPAPI's major aims were ‘elevating the issue on national agendas' and ‘building capacity to identify, contain and respond to a pandemic influenza’ (Dobriansky, 2005). Persuasion was backed by significant resources to encourage countries to take measures to detect the first signs of a pandemic quickly, and reduce the chance of its global spread. This was not always welcomed as it led to demands on poorer countries that poultry-raising practices be changed and that resources be poured into pandemic planning exercises. The dispute between Indonesia, the WHO and the developed world on virus sharing was a clear example of tensions that arise out of securitising at the global level (Elbe, 2010). Some of the consequences of this tension will be examined in a later section.

Setting the Stage for Securitisation: The Creation of an Issue Culture and the Rise of the Emerging Infectious Diseases World View

The United States was the prime mover in the securitisation of avian and pandemic influenza, and it is therefore important to look at some of the factors that enabled securitisation there. While the Copenhagen School's analysis explains how securitisation takes place, as Sandra Maclean (2008) has observed, it is less successful in explaining why. It is important to try and examine the conditions that made pandemic influenza seem a credible risk to security and allowed securitisation.

Perceptions of risk at the societal level are an important precondition to securitising an issue. Unless a society is primed to perceive a threat as posing an existential risk, it will be difficult to securitise that risk. Infectious diseases have been described as ‘dreaded risks’, and therefore more susceptible to being seen as threats to security (Enemark, 2007). But why are infectious diseases seen as dreaded risks? The psychometric paradigm of risk pioneered by Paul Slovic lays out some of the factors that lead people to perceive certain risks as dreaded: these include risks that are catastrophic, involuntary and of high risk to future generations (Slovic, 1987). Slovic's taxonomy is extremely useful, but it also begs the question of why people perceive these risks in such a way? What are the social factors that might prime people to perceive certain risks as dreaded?

In an attempt to answer this, and also to throw more light on the perceptual factors that led to the securitisation of influenza, this article suggests that the presence of an ‘issue culture’ or interpretative discourse around a threat moulds perceptions of risks, and also makes securitisation credible.

In the case of pandemic influenza, a key factor in securitisation appears to have been the existence within the United States of an issue culture around emerging infectious diseases and pandemic influenza. It is argued here that the existence of such a discourse, and its acceptance by policy makers and audiences in the leading centres of global power, played a role in developing the securitisation of emerging infectious diseases in general, and pandemic influenza in particular. After the events of 11 September 2011, and in particular the anthrax attacks that followed, this emerging infectious disease discourse was strengthened and gained salience through concerns about bioterrorism and through the securitisation of public health that occurred after public health institutions and officials were drafted into the war against bioterrorism (Kelle, 2005).

To examine the creation of this discourse, and also explain the reasons for securitisation, I use William Gamson and Andre Modigliani's (1989) description of how issue cultures or discourses are created. For an issue culture, or a particular interpretative discourse, to gain prominence, Gamson and Modigliani suggest three determinants: the issue needs to have powerful sponsors; it needs to have cultural resonance; and the messages need to have a successful fit with media norms and practices. I will look at each of these determinants in the context of pandemic influenza.

The ‘sponsors' of this issue culture were a group of influential scientists in the United States, who from the late 1960s had begun to issue warnings about the threats posed to the United States (and indeed global society) by the emergence of previously unknown viruses. One of the earliest examples of what Neil King (2002) has described as the ‘emerging diseases world view’ was a column in the Washington Post in September 1968 by Joshua Lederberg, a Nobel Prize-winning biologist, in which he warned against the threat to human existence posed by exotic viruses (Lederberg, 1968). The warning was provoked by an incident that had occurred that summer when African green monkeys imported from Uganda to a laboratory in Marburg, Germany, infected 32 people with a previously unknown virus, causing horrifying disease and death in a high proportion of cases. Because the infections had occurred among laboratory workers, it was contained, and did not spread to the wider population. But for Lederberg this was a portent of the existential threat that diseases caused by hitherto unknown viruses posed to human existence. ‘The threat of a major virus epidemic – a global pandemic – hangs over the head of the species at any time’, he wrote. ‘What might have been an epidemic of world shaking dimensions was contained by sheer good luck.’ Lederberg ended his column with a call for better preparation to face such viral threats, a warning that he was to sound repeatedly over the coming decades: ‘Marburg virus is but one example of the evils of nature that are our real enemies in the living world … And as human society is now organized our encounters with such threats will not for long be just near misses’.

In May 1989, following the identification of more examples of infectious diseases caused by previously unknown viruses of zoonotic origin such as Ebola and HIV, Lederberg, his colleague Robert E. Shope and a number of prominent scientists and public health experts including the virologist Stephen S. Morse convened a conference on emerging viruses highlighting the potential microbial threats that the United States faced. Three years later, this was followed up by a book edited by Lederberg and Shope published by the Institute of Medicine (IOM) which explicitly called for a global strategy for emerging infectious diseases (Lederberg et al., 1992). Among the recommendations they made were for the US to ‘take the lead in promoting the development and implementation of a comprehensive global infectious disease surveillance system’ that would help the early detection of new diseases wherever they might occur in the world (Lederberg et al., 1992, p. 6). The IOM report created the foundation for a new focus on emerging infectious diseases framed as global threats to the United States coming from overseas.

The mass media play a key role in the setting of the public agenda, and the emerging infectious disease discourse benefited from key media figures who were receptive to this message. Two respected journalists, Laurie Garrett and Richard Preston, produced influential books and articles that helped focus the attention of decision makers on the threat posed by viral agents both arising within the United States and coming from abroad. Garrett won a Pulitzer Prize in 1996 for her reporting on Ebola, followed up by a meticulously researched and compelling account of the threat posed by new infectious diseases in The Coming Plague: Newly Emerging Diseases in a World Out of Balance (Garrett, 1995). Richard Preston's The Hot Zone, which spent several months on the New York Times bestseller list, was an account of an incident in which monkeys in a research facility in Reston, Virginia, were infected with a variant of the Ebola virus, later named Ebola Reston (Preston, 1994). Written in an often breathless ‘bio-thriller’ style, the book spans the viral ‘hot zones' of Africa to Bio-safety suit clad scientists in labs in the United States, and probably had a particular impact because of the proximity of the lab in which the Ebola-infected monkeys were found to the US capital. King observes that ‘Garret and Preston ensured that emerging diseases remained front-page news throughout the 1990s' (King, 2002, p. 770).

There are other examples of growing media receptivity to the emerging infectious diseases message. A coordinated effort in 1996 by 36 medical journals across the world to devote their issues to emerging infectious diseases also received significant media coverage. Under the headline ‘Infectious Disease Threat Rises, Doctors See New Risk of Global Epidemics’, the Chicago-Sun Times warned against the ‘rapid spread of new killer diseases' and quoted an editorial by Lederberg in the Journal of the American Medical Association (JAMA) stating that the world had ‘never been more vulnerable’ to new diseases (McNamee, 1996).

As important as the fact that key media figures supported and disseminated these ideas was the absence of any authoritative scientific voices dissenting from this world view. Journalistic practices require ‘balance’ between opposing views, but in this case there were no authoritative opposing views, and the emerging infectious diseases world view was presented as a definitive picture of reality.

In Gamson and Modigliani's analysis, it is not enough to have influential sponsors and media support for an issue to gain public acceptance. The issue needs to resonate with public concerns. In this case, anxieties about the consequences of modernity and globalisation and the risks that flowed from them provided the broader context within which the emerging infectious disease world view of humanity threatened by viruses played out. The rise of ‘non-traditional’ threats to society in the post-Cold War world, coming not from other nation states, but from non-state actors like terrorist groups, as well as the adverse consequences of modernisation, ranging from environmental degradation to industrial accidents, climate change and disease, pose threats to Western middle-class lifestyles, and create a crisis of ‘ontological security’ (Pereira, 2008). Similarly, King situates the rise to prominence of the emerging infectious diseases world view as an expression of American anxieties ‘about living in a globalizing world, in which the assumptions and institutions of the Cold War era no longer seemed adequate to the task of ensuring the safety and interests of US citizens' (King, 2002, p. 764).

It has been persuasively argued that all states require a discourse of danger to remain credible and in order to maintain their identity (Campbell, 1992). In the United States particularly, it has been argued by David Campbell that, in the post-Cold War world, reproducing the identity of the United States is likely to require new discourses of danger, candidates for which include diseases such as AIDS as well as more general threats from terrorism (Campbell, 1992, p. 196).

Emerging infectious diseases caused by exotic viruses are in many ways a perfect example of the anxieties caused by modernisation. The view that mankind would prevail over pathogens was replaced by a non-linear, postmodern understanding in which such an outcome was no longer certain (Ingram, 2008). The social and cultural context within which the emerging infectious disease world view took root can also be understood in the context of the anxieties caused by changes in the world order from one of US dominance to a situation in which the United States is beset by threats, enemies and global anarchy, and where the world is divided between ‘tame zones' of wealth and security and ‘wild zones' of poverty and violence (Ó Tuathail, 1996).

The threat of exotic viruses coming from the world's ‘wild zones' fitted well into this anxious, postmodern world view, and found resonance in popular films, books and other cultural products. By the mid-1990s viruses appeared to have captured the public imagination as the ‘new other’ that threatened the United States, a foe against which boundaries and defences needed to be created. Heather Schell (1997, pp. 94–5) observed that viruses appeared to have taken over from the Soviets as the new enemy, and that ‘lethal new viruses have become a hot topic for science best-sellers, medical research, action movies, and science fiction. On the big screen, virus thrillers like Outbreak and Twelve Monkeys have attracted major stars and large audiences’. A key feature of the books and movies on emerging infectious diseases was the geography of their narratives. The viruses all came from outside the United States: either from Africa or from unnamed tropical locales. Schell observes: ‘Even authors who do not focus on Africa frequently retain the assumption that viruses are foreign entities, possibly even anti-American’ (Schell, 1997, p. 102).

The infectious disease world view percolated to the level of government during the Clinton administration. A report by the CIA's National Intelligence Council in January 2000, entitled The Global Infectious Disease Threat and Its Implications for the United States, explicitly described infectious diseases as a national security threat to the United States:

New and re-emerging infectious diseases will pose a rising global health threat and will complicate US and global security over the next 20 years. These diseases will endanger US citizens at home and abroad, threaten US armed forces deployed overseas, and exacerbate social and political instability in key countries and regions in which the United States has significant interests (NIC, 2000, p. 5).

The concerns felt in the United States, the world's most powerful nation and the leading actor in global politics, soon spread out into the rest of the global system. As Fidler (2003)

noted, the argument from the world's remaining superpower that pathogenic microbes represented a national security threat raised the profile of infectious disease both in the United States and beyond. In 2000 the United Nations Security Council discussed the impact of HIV/AIDS on sub-Saharan Africa, marking the first time that the Security Council had debated a microbial foe (Fidler, 2003). The then US vice-president, Al Gore, set out the case for regarding HIV/AIDS as a security threat in his speech to the Security Council: ‘the heart of the security agenda is protecting lives – and we now know that the number of people who will die of AIDS in the first decade of the 21st century will rival the number that died in all the wars in all the decades of the 20th century’ (cited in Peterson, 2002, p. 43).

This search for security concepts that would address the new threats of the post-Cold War world led to several international reports, including those by the Commission on Global Governance and the UN Secretary-General's Commission on Human Security, which widened the traditional notion of security to include the security of individuals as well as nation states, or as the UN Secretary-General, Kofi Annan, described it, ‘the security of people in their homes, jobs and communities' (cited in Rothschild, 1995, p. 56).

The World Health Assembly had in 1995 adopted a resolution on new, emerging and re-emerging diseases and another one on updating the IHR, the legal framework that obliged states to report certain infectious diseases to the WHO (see Youde, 2011, this issue). The WHO began using the term global health security in 2001 to describe the global public health measures required to protect the world from transborder infectious disease threats, marking a step in the securitisation of diseases (WHO, 2001).

Thus by the end of the 1990s an issue culture, or an interpretative framework, was in place in the United States that was sensitive to the potential impact that disease could have on national security.

Lending Salience to the Emerging Infectious Diseases World View: 9/11, Bioterrorism, SARS and H5N1 Avian Influenza

If the circumstances described earlier created a context in which infectious diseases were seen as security threats, a series of events beginning with the 9/11 attacks on New York and Washington and the anthrax attacks that followed seemed to provide confirmation of this threat and provided salience to the discourse that had been created earlier.

The anthrax attacks pushed along the process of securitisation of emerging infectious diseases by blurring the distinctions between naturally occurring infectious diseases and deliberate acts of bioterrorism and placing the response to both within a security framework. The then US Secretary of the Navy, Richard Danzig, noted after the anthrax attacks that ‘only through a new union of our public health, police and military resources' could the threat of bioterrorism be met (cited in Garrett, 2001, p. 86). Fears that the anthrax attacks would be followed by a deliberate release of smallpox virus in the United States and widespread news reports about the threat posed by smallpox served to draw public health into the discourse of national security and defence.

These US concerns were reflected at the global level. The US Health Secretary, Tommy Thompson, led the creation of the Global Health Security Initiative (GHSI), which brought together the health ministers of the G7 countries, the European Union, with the WHO as a technical adviser. Canada hosted the first meeting in November 2001, where the ministers agreed ‘to forge a partnership to address issues of protecting public health and security globally’ and called for ‘global action to strengthen public health preparedness and response to the threat of international biological, chemical and radio-nuclear terrorism’ (GHSI, 2001).

While the anthrax attacks demonstrated the security fears raised by a bioterrorist event, the SARS epidemic in early 2003 demonstrated how disruptive a newly emerged virus could be in a globalised world. SARS managed to cripple some of the most dynamic cities in the world, and is estimated to have led to a loss in global economic output of US$20–25 billion (World Bank, 2003), even though in purely public health terms SARS was not a particularly serious disease. SARS' real impact was to sensitise the world to future infectious disease threats and demonstrate the dangers that Lederberg and others had warned against. In the West, it also helped to reinforce the notion that emerging infectious diseases always came from somewhere else, whether it was Africa or Asia.

Had SARS not come along, it is not clear whether the next health threat that captured global attention – the H5N1 avian influenza virus – would have been taken as seriously as it was. The H5N1 virus first came to the fore in the spring of 1997, when it killed over 5,000 birds on poultry farms in Hong Kong. The outbreak did not attract much attention outside the world of animal health until May that year when a three-year-old boy in Hong Kong died after being infected by the virus. This was the first time that the H5N1 virus had been known to infect humans and cause disease (Webster et al., 2006). The Hong Kong government ordered the mass culling of all domestic poultry in the region, and no further cases were detected either among birds or human beings for several years.

When the H5N1 virus next appeared in early 2004, first in Vietnam and then later in nine other Asian countries including China and Japan, it appeared in a post-SARS context, when there was greater sensitivity to the potential for the global spread of a new disease. Within the United States, where anxieties over anthrax and smallpox had subsided, attention shifted to the threat posed by this new virus. In a post-9/11 world when the United States was acutely sensitive to threats from abroad, it made sense to prepare for this potential threat as well.

Infectious disease and flu experts expressed great certainty about the dangers posed by the H5N1 virus. For example, in an influential article in Foreign Policy, Michael Osterholm sketched out in stark terms the consequences of a pandemic caused by the H5N1 avian flu virus:

The impact of a pandemic caused by the current H5N1 strain would be similar to that of the 1918–19 pandemic … if 1918–19 mortality data are extrapolated to the current US population,

1.7 million people could die, half of them between the ages of 18 and 40. Globally, those same estimates yield 180–360 million deaths, more than five times the cumulative number of documented AIDS deaths (Osterholm, 2005, p. 26).

The then head of the US Centers for Diseases Control and Prevention (CDC), Julie Gerberding, warned that the world could be on the brink of an influenza pandemic caused by the H5N1 virus (Recer, 2005).

While the warnings themselves were not new, the US government and Congress, sensitised to the potential for disaster from abroad, were now primed to prepare for this threat, and the process of securitisation described earlier now began. The WHO too began to sound increasingly dire warnings about the possibility of the H5N1 virus igniting a pandemic. The Director-General of the WHO at the time, Dr J. W. Lee, described the outbreaks as ‘a serious global threat to human health’ while the head of the WHO's regional office in the Western Pacific, Dr Shigeru Omi, told a meeting of Asian health ministers in Bangkok in December 2004 that ‘we are talking at least 7 million [deaths], but maybe more – 10 million, 20 million and the worst case 100 million’ (McDonald, 2004).

Did the facts on the grounds warrant such certainty? The H5N1 virus had a devastating impact on poultry in the region. Thailand, a major chicken exporter, was particularly hard hit, with a large proportion of its commercial flocks either culled or killed by the virus. Vietnam also suffered; its economic losses were estimated to be several hundred millions of dollars. But while H5N1 was a major animal health and economic threat, it was not a human health threat to anywhere near the same extent. In 2004, there were 46 human cases, of whom 32 died. Although the virus had spread throughout South-East Asia, the majority of cases (29) were in Vietnam. Given the prevalence of the virus in domestic poultry and ducks, and the numbers of human beings who would probably have come into contact with infected animals, the occurrence of human cases was surprisingly small. H5N1 was clearly a bird virus, which on rare occasions infected human beings. There was also no evidence that infected human beings were able to spread the disease to other humans, a crucial requirement for a virus to cause pandemic influenza. It was true that when the virus did infect human beings, the disease it caused was severe, and the mortality rate high. But this would normally have placed H5N1 in the same category as other diseases with high fatality but low transmission rates, such as Ebola.

Subsequent events have shown that the H5N1 remains an animal virus, which occasionally infects human beings. Since 2003, while the H5N1 virus has spread to domestic and wild bird populations in Asia, Europe and Africa, there have only been 504 human cases, the majority from Egypt, Indonesia and Vietnam, with 299 deaths. While the H5N1 virus has evolved, it has not so far displayed any greater ability to transmit from human to human.

It was significant that there were no dissenting voices in public, from scientists or public health practitioners, regarding the emphasis given to a possibly imminent pandemic caused by the H5N1 virus. This was despite the fact that in many developing countries the disease burden from other infectious diseases was greater than from influenza, and that planning and preparing for an influenza pandemic meant a diversion of resources away from other priorities.

The factors discussed earlier, such as the building up of the emerging infectious diseases threat and its framing as a national security issue in the United States and the West; the anxieties over bioterrorism caused by the anthrax attacks; the ability of the US to ensure that global organisations such as the United Nations and its specialised agencies like the WHO were responsive to US needs; and the experience of SARS, created a framework or discourse within which a pathogen like H5N1 was almost automatically regarded as a threat warranting a global response.

Conclusion: Some Consequences of Securitisation of Health in a Hierarchical World Order

This article has tried to delineate the processes and the conditions by which avian and pandemic influenza came to be securitised by the United States and the international community. Based on the impact that the pandemic of 2009 had, it can be argued that securitisation was not warranted. But regardless of whether pandemic influenza turned out to be a serious disease or not, what is of interest here is the process and conditions by which a disease is securitised at the global level.

The securitisation of a disease as a global health threat would require the United States to initiate the process (or at the very least support it). It will do so if this disease is perceived to pose an existential threat. What conditions are required for such an existential threat to be perceived? The analysis in this article suggests that prior perceptions of risk must exist around the phenomenon being securitised. These perceptions can be created through an issue culture or interpretative discourse which highlights the dangers that the phenomenon poses. This discourse must enjoy support in the media, preferably unchallenged by alternative discourses. The discourse itself must have social and cultural resonance, and be given salience by events, so that the threats are seen as credible. The securitisation of avian and pandemic influenza followed this pattern. Further studies are required to see whether other global disease threats that are securitised in the future follow a similar pattern.

A problem that arises from the securitising of a global health threat on the basis of the threat perceptions of dominant countries in the global political system is that countries lower down in the global economic and political pecking order are compelled to devote extraordinary attention and resources to issues that might not pose a grave threat to them. Avian and pandemic influenza was for many developing countries just one out of a multiplicity of infectious disease threats. For example, in April 2009, when the pandemic virus began to cause outbreaks in Mexico and the United States, there were other bigger disease threats in other parts of the world. To take a few examples: Nigeria was battling an outbreak of meningococcal disease which had led to over 5,000 cases and 300 deaths; Sudan was confronting a polio outbreak; Zimbabwe was in the throes of a prolonged cholera outbreak; Thailand was coping with over 6,000 cases of chikungunya; and São Paulo in Brazil was confronting an epidemic of urban yellow fever. Each of these diseases had a greater impact in their respective countries than the influenza pandemic caused. Yet the securitisation of pandemic influenza led to global attention and resources being focused on influenza.

The debate on whether health issues should be securitised and the benefits and risks of doing so have been extensively discussed (Elbe, 2006; Maclean, 2008; McInnes and Lee, 2006). What is clear is that health issues will be securitised at the global level when leading powers feel it is in their interest to do so. But not all countries will feel the same degree of threat that the initiators of securitisation feel. However, until a more equitable global society is created, they will have little choice but to go along with the leading powers.

Note

The author would like to thank the anonymous peer reviewers as well as participants in the Global Health Governance workshop held at Sheffield University in November 2010 for their comments, which helped greatly to strengthen this article.

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