Reshaping global health architecture: African health sovereignty as the foundation of global health equity and security.

To the Editor: Global health security is the protection of the health of persons and societies worldwide. It includes access to medicines, vaccines, and health care, as well as reductions in collective vulnerabilities to global public health events that have the potential to spread across borders. For example, transboundary zoonotic diseases such as avian influenza (H5N1) infections affect animals and humans, thereby threatening health security worldwide because of their high death rates (≈60% in humans) (1). During the past 15 years, fairly standardized responses to threats have been implemented around the globe. Some of these responses have been against severe acute respiratory syndrome and avian influenza (H5N1), which have been overseen by a well-resourced international health system (2). These global health threats have raised the highest levels of political and social concern. This concern has provoked governments and international agencies to address health threats through a security rationale, which emphasizes the themes of national security, biosecurity, and human security. This amalgamation of health issues and security concerns has produced a notion of health security, which is dominated by technical medical approaches and pharmaceutical interventions. These approaches and interventions have already begun to shape the way international health policy is formulated (3). A global vision of health security is very much part of contemporary rhetoric. However, this vision lacks the drive and speed needed to make proposals materialize and operationalize ideas in the geographic areas where they are most desperately needed. Small benefits accrue to members of vulnerable populations who in fact are those most likely to be affected by epidemic diseases. A public health security design that impinges on a global approach runs the risk of neglecting cultural, economic, ecologic, and social conditions on the ground. Regional approaches that address hazards and threats may be more inclusive of context-specific conditions (4). Global public health threats related to infectious pathogens of animal origin are expected to rise. To address these threats, several experts and strategists suggest the initiation of a worldwide early-alerting and -reporting mechanism. Aggregation of disease threats through an event-focused Web-based platform could enable this mechanism. This timely gathering of disease intelligence can inform policymakers about the nature of risks. Disease maps can display details needed to design tailored policies and control measures to tackle diseases according to their specifics (5). Leading scientists and researchers continue to try to understand the global temporal and spatial patterns of animal diseases. This understanding is gained through an array of instruments, ranging from the use of satellite images to cutting-edge molecular technologies. The momentum so far has created an open forum for decisionmakers to collaborate with the leading international agencies to advocate for surveillance, identification, and control of zoonotic diseases to uphold global public health security (6). However, global initiatives suffer from the free-rider problem and from moral hazards. Some low-income countries with weak governance have alerted the international community about their fragile health care systems to capture a nontrivial portion of funds that seldom reach their intended destinations. These resource allocations to developing countries foster aid dependence (7). The international technical agencies tasked with upholding animal and human health should remain at the forefront of identifying and addressing evolving threats. This process will demand continuous flexibility, agility, and a coordinated international effort. Attaining goals of mitigating threats and reducing risks posed by the emergence of zoonoses requires close collaborations with national health authorities and local governments. The large investments planned to improve foresight and prevention might or might not work. If they do not work, apportioning blame to countries or regions for disease flare-ups can result in social, political, cultural, and economic consequences that in the past have turned out to be unjustified, unfair, and ultimately detrimental (8). Clearly, global health threats can be reduced only by the concerted actions of national and international actors. In the years ahead, the international community will almost certainly be expected to bring its formidable technical knowledge, skills, and analytic capabilities to confront this expanded global health threat environment (9). It would be wrong, however, to forget the many insights that current advances in epidemiology and surveillance have delivered. In fact, should the impetus to finance a global health agenda encounter opposition or obstacles, it would seem easier and logical to strengthen already functional activities. Lastly, the realities and the prevalent policymaking environment have created a trap between a desire to prioritize global health by portraying aspects of it as an existential security issue and the fact that security ultimately might not be the most useful language for describing and institutionalizing the health threats and hazards confronted by societies around the world (10). Regardless of whether a trap has been created, action is urgently needed.

Global Health Security

The concept of global health security underpins the current framework for global preparedness and response to emerging infectious diseases. (1-5) The Global Health Security Agenda--a collaboration between governments--was launched in 2014, aiming to make our interconnected world safe from infectious disease threats. The governments involved in the Global Health Security Agenda focus on strengthening their countries' capacities for detection, response and prevention. (6) In the context of public health emergencies, the Agenda has received financial and political support from international organizations and almost 50 countries. (6) However, there is tension between the aims of global health security and governments' mandate to ensure national security. The 1994 United Nations Development Programme's Human Development Report first introduced the concept of human security, referring to security of citizens as individuals rather than that of the states in which they live. We posit that the use of the term global health security can have a negative unintended effect on the ultimate goal of improving health for all. There are three reasons why this term potentially privileges the security of the state rather than the security of individuals. First, global health security, in its current use, is largely focused on protecting high-income countries against public health threats coming from low- and middle-income countries. (8) Ebola virus, Marburg, Zika virus, dengue, chikungunya, Riff Valley and Lassa fevers, originated in low--and middle-income countries. If the Agenda is used to prioritize global health risk depending on the origin of infections, resource allocation may become even more skewed towards high-income settings. To ensure that a health security agenda is an integral part of national and foreign policy of each country, political attention and coordination between national ministries is needed as well as support from the national security budget. Second, global health security tends to emphasize disease containment to protect national security rather than the prevention of future local outbreaks. Disease containment is common practice in the control of emerging infectious diseases. A national security perspective often results in unilateral, neo-colonial and/or short-term solutions designed to protect national borders. For example, many countries and airline companies imposed travel restrictions during the 2013-2016 Ebola virus disease outbreak in western Africa, contrary to World Health Organization recommendations. (9) Third, we argue that respect for human rights and values such as equity and solidarity should underlie each national security agenda. Such values are consistent with the motives of many people who provide health services in public health emergencies. Health security agendas should aim to build resilience to future outbreaks of infectious diseases, and require a long-term systems approach based on surveillance and national health system strengthening. Protecting the world from infectious disease threats requires that national governments share the responsibility of serving those most in need, wherever they live. We believe that the concept of global health security should be expanded to include solidarity and sustainability. …

This article was published in the BMC Infectious Diseases [© 2017 BMC Infectious Diseases] and the definite version is available at : https://doi.org/10.1136/bmjgh-2016-000217 . The Journal's website is at: http://gh.bmj.com/content/2/1/e000217

Reviewed by: Unprepared: Global Health in a Time of Emergency by Andrew Lakoff Limor Samimian-Darash Andrew Lakoff. Unprepared: Global Health in a Time of Emergency. Oakland: University of California Press, 2017. 240 pp. $29.95. (978–0–52029–576–6). This book joins the recent literature that examines future intervention technologies and identifies a new modality of securing against “future threats” that goes beyond Foucauldian biopolitical security apparatuses. Preparedness within this framework involves multiple techniques emerging in response to the problem of potential uncertainty.1 One of the first works to present this approach was Andrew Lakoff and Stephen Collier’s edited volume on Biosecurity Interventions.2 In their introduction, the editors argued that preparedness combines elements of national security and population security and is directed toward reducing potential damage rather than preventing specific threats. Subsequent studies have also identified related governmental forms, variously termed “preparedness,”3 “anticipation,”4 “precaution,”5 “preemption,”6 “prudence,”7 “the politics of possibilities,”8 and “resilience.”9 The present book shows how a global health security assemblage consisting of diverse elements, experts, and technologies has established “preparedness” as its central governmental modality. It traces both the roots of preparedness from the end of the Cold War to the present and the emergence of this [End Page 723] assemblage, analyzing how relevant authorities—public health officials, national security experts, and life scientists—conceptualize and act on an encroaching future of disease emergence. Significantly, the book focuses not only on the changing mode of governing—the emergence of preparedness—but also on the diverse governmental technologies applied within this approach. If the problem has shifted from knowledge-dependent possibilities (accidents, risks), manageable by means of risk technology, to potential threats, what types of intervention technologies become possible? The book seeks neither to provide a manifesto for the importance of preparedness nor to criticize its failures. Instead, drawing on the perspective of historical ontology, it tracks the emergence of an unstable consolidation of global health security, posing the question: “How did the norm of preparedness come to structure expert thought and action concerning the future of infectious disease?” (p. 12). Each chapter draws on a different case study to explore how uncertain global health threats can be addressed and made into an object of present intervention, according to different and sometimes competitive rationalities, such as probability, and imaginative enactment, risk assessment, and preparedness. Chapter 1 presents the case of Hurricane Katrina (2005), focusing on how “contemporary authorities seek to manage potential future dangers . . . whose probability cannot be statistically calculated and whose potential consequences outstrip the capacities of existing prevention and mitigation measures (p. 8).” It distinguishes between two forms of thinking about and intervening on the dangerous future and its potential threats: as a regularly occurring event that can be calculated via probabilities (based on known historical patterns) and managed through risk distribution, or as an unprecedented, potentially catastrophic event whose consequences are to be managed through methods of imaginative enactment (enabling planners to mitigate vulnerabilities). Chapter 2 discusses the 1976 swine flu outbreak and the 2005 avian influenza threat in the United States, examining how techniques of emergency management migrated to and were implemented within U.S. public health. This “involved the composition of a new object of knowledge and intervention for public health: no longer, or not only, the population but also the infrastructure that underpins response to health emergencies” (p. 9). Chapter 3 discusses the controversy surrounding Indonesia’s refusal to provide the WHO with samples of a new strain of the H5N1 influenza virus. It examines how, from the early 2000s, public health preparedness was extended as a global strategy in relation to the threat of emerging disease, focusing on the development of the 2005 revised International Health Regulations that form part of the WHO’s strategy of “global public health security.” Here, an analytic distinction is made between two regimes for governing global health problems: global health security and humanitarian biomedicine. Chapter 4 examines the controversy over the WHO’s decision to declare a Public Health Emergency of International Concern over the 2009 swine flu (A\ H1N1) outbreak. It shows how decision instruments for guiding emergency interventions at the early stages...

Within the global health landscape exists a complex interplay between global health security (GHS) and universal health coverage (UHC)—two influential agendas with profound influence on health system strengthening initiatives. There is a need to understand why and how coherence between GHS and UHC is being pursued in health policy and planning, particularly in the wake of the COVID-19 pandemic which profoundly reshaped the field of global health and significant cuts to global health assistance. This paper presents one of the first detailed analyses of contemporary efforts to conceptualize and operationalize GHS–UHC coherence—through the perspectives of key actors responsible for its implementation. The study employed thirty-one interviews with senior officials across four major types of global health actor: multilateral and global health organizations, country governments, donors and international finance institutions, and civil society organizations. It reveals important insights into the way specific actor and geopolitical groups varied in terms of shifting perceptions of GHS and UHC, as well as major factors influencing GHS–UHC coherence (e.g. strategic considerations including motivations and concerns, and structural considerations including enablers and barriers). The analysis suggests that an emerging ‘hybrid norm’ linking GHS and UHC appears to be well underway. It further contends that strengthening coherence between GHS and UHC not only depends on, but also enhances, three key imperatives: (i) overcoming geopolitical power asymmetries, (ii) leveraging strategic collaboration across actor types, and (iii) pursuing integrative health diplomacy amid overlapping crises. While this study centres on GHS–UHC alignment, its broader objective is to foster a more equitable and resilient global health architecture by tackling the interconnected causes of fragmentation through hybrid normative frameworks. By focusing on the politics of norms underpinning GHS and UHC integration, this work contributes to rethinking how global health institutions collaborate, ultimately helping to build more sustainable global health governance fit to withstand future political, economic, and social challenges.

The concept of ‘health security’ has been increasingly apparent in recent years in both academic and policy discourses on transborder infectious disease threats. Yet it has been noted that there are a range of conceptualisations of ‘health security’ in circulation and that confusion over the concept is creating international tensions with some states (particularly from the Global South) fearing that ‘health security’ in reality means securing the West. This article examines these tensions but puts forward an alternative explanation for them. It begins by looking at the different ‘health securities' that characterise the contemporary global health discourse, arguing that there is in fact a good deal more consensus than we are often led to believe. In particular there is a high level of agreement evident over what the major threats to ‘health security’ are and what should be done about them. These are a particular set of health risks which are primarily seen as major threats by Western developed nations, and contemporary global responses – often couched in the language of global health security – have a tendency to focus on containment rather than prevention. The article makes the case that to resolve the tensions around (global) health security there is the need for a more explicit recognition of the primary beneficiaries of the current system, and of who is bearing the costs. Only following such a recognition can meaningful debates be carried out about the appropriate prioritisation of global health security in relation to other global health governance priorities.

This paper evaluates global health responses to the COVID-19 pandemic through the ‘two regimes of global health’ framework. This framework juxtaposes global health security, which contains the threat of emerging diseases to wealthy states, with humanitarian biomedicine, which emphasises neglected diseases and equitable access to treatments. To what extent did the security/access divide characterise the response to COVID-19? Did global health frames evolve during the pandemic? Analysis focused on public statements from the World Health Organization (WHO), the humanitarian nonprofit Médecins Sans Frontières (MSF), and the American Centers for Disease Control and Prevention (CDC). Following a content analysis of 486 documents released in the first two years of the pandemic, the research yielded three findings. First, the CDC and MSF affirmed the framework; they exemplified the security/access divide, with the CDC containing threats to Americans and MSF addressing the plight of vulnerable populations. Second, surprisingly, despite its reputation as a central actor in global health security, the WHO articulated both regime priorities and, third, after the initial outbreak, it began to favour humanitarianism. For the WHO, security remained, but was reconfigured: instead of traditional security, global human health security was emphasised – collective wellbeing was rooted in access and equity.

Offline: Global health security—smart strategy or naive tactics?

ABSTRACTIn recent years the framings of global health security have shifted while the structures governing global health have largely remained the same. One feature of the emerging re-ordering is the unresolved allocation of accountability between state and non-state actors. This brings to critical challenges to global health security to the fore. The first is that the consensus on the seeming shift from state to human security framing with regard to the global human right to health (security) risks losing its salience. Second, this conceptual challenge is mirrored on the operational level: if states and non-state actors do not assume responsibility for health security, who or what can guarantee health security? In order to address global health security against the backdrop of these twenty-first Century challenges, this article proceeds in three parts. First, it analyses the shortcomings of the current state-based World Health Organization (WHO) definition of health security. Second, taking into account the rising pressures posed to global health security and the inadequacy both of state-based and of ad hoc non-state responses, it proposes a new framing. Third, the article offers initial insights into the operational application of beyond state responses to (health) security challenges.

This chapter begins by discussing the role of the WHO in the politics of global health, its mandate, authority and funding, with particular emphasis on the governance of emerging infectious diseases. As an intergovernmental organisation, the WHO derives its legitimacy and authority from its member base, and this has influenced its ability to act in the field of global health insofar as individual state interests often forestalled an international cooperative response. On the other hand, since the end of the Cold War, emerging infectious diseases have increasingly been identified as posing a serious global risk, which triggered a discourse of global (public) health security, promoted especially by some Western WHO members and the organisation itself. This discourse has motivated new institutional developments in the WHO and in global health governance more generally. Specifically, it elevated the WHO to be the main actor in coordinating global disease surveillance and containment in global health emergencies. The chapter then shows how the governance of emerging infectious diseases over the past two decades has been plagued by the ceaseless discursive struggles between state sovereignty and global health security, and this despite the WHO’s new central role and relative autonomy. The chapter traces this tension in the global response to three consecutive international infectious disease outbreaks preceding the Covid-19 pandemic. The conclusion discusses the dynamics of international collaboration in response to the current, still unfolding, pandemic as well as the challenges faced by the multilateral WHO moving forward.

The study examines the role of international organizations, specifically the World Health Organization (WHO), in managing global health security in Africa. It evaluates WHO’s effectiveness, the impact of systemic inequality in resource allocation, and the consequences of delays in decision-making and operational inefficiencies. The research is anchored in regime theory, which explains how international organizations govern global health security through established norms and cooperative frameworks (Krasner, 1983). A qualitative research design was employed, utilizing data from WHO reports, global health indices, and case studies of past health crises, such as Ebola (2014–2016) and COVID-19 (2020–2024). Data were collected from WHO publications, African CDC reports, peer-reviewed journals, and government health statistics. Findings reveal that WHO plays a pivotal role in disease surveillance, emergency response coordination, and health policy implementation. However, systemic inequalities in funding and material distribution have limited Africa’s ability to respond effectively to health crises. Delays in WHO’s decision-making processes have further exacerbated the impact of pandemics on the continent. Despite these challenges, WHO remains a key institution for strengthening health security, provided that operational inefficiencies are addressed, resource distribution becomes more equitable, and decision-making processes are restructured. The study recommends decentralizing WHO’s regional offices in Africa, improving health equity in resource allocation, and reducing bureaucratic inefficiencies to enhance rapid emergency response. These findings contribute to ongoing policy discussions on global health governance and sustainable health security strategies for Africa.

Effective post-pandemic governance must focus on shared challenges

A new force seems to be at work in public health law and practice. Consider, for example, the proliferation of references to ‘preparedness’; specifically, ‘public health emergency preparedness’ and its more specialised variants such as ‘public health emergency legal preparedness’ and ‘international legal preparedness’. There is also increasing use of related phrases such as ‘global public health security’ and ‘international health security’. Of course, a proliferation of terms is not enough to prove that a new force is in play: language shifts all the time in all sorts of areas, and although such changes may reflect and contribute to deep social transformation, they can also be nothing more than passing fashions with little or no impact. But public health emergency preparedness does not feel like a superficial, short-lived trend: in fact, it seems almost the exact opposite. Indeed, as David Fidler and Laurence Gostin emphasise in their recent book, Biosecurity in the Global Age, a ‘policy revolution’ seems to have taken place – a revolution brought about by a ‘collision’ of public health and security.1 The collision of security and public health is our focus in this article. But before explaining why, we need to define ‘public health emergency preparedness’, in particular its impressive–sounding correlate, ‘global public health security’, and its less readily comprehensible subset, ‘public health emergency legal preparedness’. In the World Health Report 2007, Dr Margaret Chan, Director-General of the World Health Organization (WHO), described ‘global public health security’ as ‘the reduced vulnerability of populations to acute threats to health’.2 Later in the same report, more detailed definitions were provided: Public health security is … the activities required, both proactive and reactive, to minimize vulnerability to acute public health events that endanger the collective health of national populations. Global public health security widens this definition to include acute public health events that endanger the collective health of populations living across geographical regions and international boundaries … .[G]lobal health security, or lack of it, may also have an impact on economic or political stability, trade, tourism, access to goods and services and, if they occur repeatedly, on demographic stability.3 The other term that requires some explanation is ‘public health emergency legal preparedness’. Stated shortly, this is all about having the right laws in place and then using them in the right way in a time of public health emergency.4 In other words, it is about both legal preparedness for, and response to, public health emergencies – it is both proactive and reactive. More generally, it can be said to be an essential part of both public and global public health security, and a subset of public health emergency preparedness.

Abstract: This essay argues that the complex qualitative shift in Russian foreign policy has far-reaching implications for international cooperation on global health governance and health security. “Global health” in Russia’s new Foreign Policy Concept (FPC) is less about the country’s existence in the well-established “Global Health” architecture but more about presenting itself as a sovereign power with a global strategy based on national science, technology, and health security capacities aimed to operate more effectively during various biological incidents with strategic consequences for national security. While pandemic preparedness and the next international response to the health crisis must be more efficient, Russia is a critical starting point for thinking about the future of cooperation on global health security.