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Beyond Belief: The Work of Global Health Security

Forgetting Faith and Reason

Just a few months ago, at the end of September, the US Centers for Disease Control and Prevention (CDC) held a ‘Grand Rounds in Public Health‘ event at its headquarters in Atlanta, Georgia. The session, an installment in a monthly series intended to “foster discussion on major public health issues”, showcased a trio of public health experts reflecting on the ‘lessons learned’ from the West African Ebola crisis, now in its final twilight. Rather than a look back at the details of the response, however, the webcast was a look forward to the new programs and policy initiatives being launched under the umbrella of the Global Health Security Agenda (GHSA).[1] The GHSA—announced coincidentally as the first cases of Ebola spread undetected across West Africa in early 2014—is a US-led diplomatic collaboration designed to “accelerate the strengthening of capacities among low and middle income countries to prevent, detect, and respond to outbreaks of infectious diseases, epidemics and bioterrorism”.[2]

To a viewer like myself, the recent policy events around the Agenda have been fascinating to watch for a number of reasons. It is one of the first instances where ‘global health security’ has moved outside of the realm of policy-discourse and become a mandate for public health ‘action’. It is a framework that leans heavily on a faith in the ‘prophetic’ inevitability of the next major epidemic event.[3] But moreover, it is one site to take up Caduff’s claim “that there are other ways of bringing faith and reason into balance”; recalibrations that “offer us other possibilities of thinking about infectious disease” (2015: 29).

Inasmuch as the GHSA is precisely such a site of recalibration, the three presenters at the CDC came to the podium convinced of the timeliness of this Agenda, particularly following the Ebola crisis. Now at the end of the epidemic, the torrent of ‘lessons learned’ function simultaneously as judgment about the inadequacies of the recent past and as pressing mandate to craft a ‘safer future’. In other words, we no longer need the prophet to warn us; we must work to prepare. Their calls to action—primarily couched as reflections on the failures of the Ebola response—in many ways suggest a contracting gap in Povinelli’s ‘future anterior’; between a present moment of decision and a future moment of judgment, which—as Lakoff and others have shown—has been anticipated for some time yet.[4]

Nevertheless, following Caduff’s assertion that “faith is never without doubt”, it should not be surprising that the doubts about this Agenda have been flooding in from all directions. There has been a tremendous amount of skepticism, hesitancy, and outright criticism of these projects, alongside other efforts to ‘securitize’ public health—both from within the academy and from health and development agencies.[5] As one health systems specialist opined to me, the very idea of global health security is decidedly “anachronistic”, a relic from an age of American Empire and the War on Terror. What dramatic irony that such a timely political framework relies on such a ‘temporal incongruity’. The ‘spirit’ of the GHSA is clearly not shared by everyone in the public health community.

For at least one speaker at the September CDC event, such critique was a topic worth tackling explicitly. Addressing the criticisms of positioning public health capacity building as an issue of security, Jennifer Nuzzo, Senior Associate at the Center for Health Security at the University of Pittsburgh Medical Center (UPMC), noted, “I have heard lots of criticisms about the GHSA from people, saying it’s too American-centric, it’s too Western…[but this is about] building core public health capacities”. She concluded, suggesting that “if you don’t think that the GHSA is right for you, call it whatever you want. If you want to strengthen your capacity in the name of [tuberculosis] control, that’s fine. We just have to do something”.

This is no longer about the push and pull of prophecy and counter-prophecy. Forget faith or reason—there is work to do.[6]

Beyond Belief

For as much prickly grief, censure, and outright lamentation that the entry of security into health issues has produced, I cannot help but be struck in equal measure by which many of its proponents have dispensed with the language, or outright rejected it. On the one hand, it should not be surprising that such fervent policy-discourse might be frankly dropped or sidestepped, or deployed primarily with strategic considerations—as one architect of the early Agenda noted, you don’t have to be a believer to know that ‘security’ is where the money is. With over a billion dollars invested in programs related to the GHSA, US government offices working on global health security don’t need to be reminded of this fact.[7] On the other hand, there are some who seem oblivious to the scrutiny, suggesting that the concept of GHS simply addresses any and all “efforts to prepare for and prevent the next epidemic”—something nearly beyond argument a year after the peak of the Ebola crisis. Of course, prioritizing what exactly “must be done” in the name of preparedness is a rather uncertain process, invoking a very broad collection of endeavors; from health systems strengthening, laboratory capacity development, to biotech R&D reform, health workforce training—the list goes on.[8] Whether these experts are ‘believers’ in the counsel of the pandemic prophets or not, it’s clear that they are convinced of the work that remains to be carried out in its name.

This capricious movement between endorsement and outright disregard over the issue of ‘security’ suggests that the survival of such an idea is not (necessarily) an issue of conviction, of belief, or even faith—less a matter of a “formal pact” and something more like a “flexible partnership”. In Caduff’s incisive turn of phrase, the effort to make global health work under an umbrella of security today seems to be more about managing one’s infelicities than it is about actually meaning what one says. Nobody understands this better than the officials at the WHO after the tragedy in West Africa, who only seem eager to speak of ‘global health security’ as an “Agenda” when the Americans are around.[1] So, the question seems to be less who these actors ‘are’ or what they believe underneath their masks of strategic policy ‘as-ifs’, but rather, what kind of work can be accomplished when they are all at once on stage.

MinisterialMeeting6

The Ministerial Meeting Session, September 18, 2015, Seoul, South Korea

A Culture of Danger?         

Caduff’s work both here in Pandemic Perhaps and in his recent review article on biosecurity (2014) suggest that “to enter a world of security is to enter a world of insecurity, a world of endless suspicion, speculation, deception, anxiety, uncertainty, obscurity, and paranoia” (110). No doubt, in many instances, this is the mise-en-scène. However, working in ‘global health security’ today seems as much about entering a world of negotiated suggestions, fragile policy collaborations, and political mobilizations as it is about performative promises or the perpetual politics of Fear. The only thing one ought to feel, in other words, is urgency. Caduff’s turn to the dramaturgical seems one powerful way to address this strategic as-if that positions the ironic tone of what ‘security’ means today in the world of global health.

In some ways, this is a (by)product of the contingency of contemporary global health projects. That is to say, GHS today does not name a set of stable commitments or projections, but rather a number of rapidly shifting possibilities and projects. Like the radically indeterminate ‘viral clouds’ of influenza that Caduff traces at the benchside, the policy maelstrom surrounding global health security is at once ambiguous, infectious, and powerful. Yet, it is striking that a project that aims at such a profound reconfiguration of the coordinates and stakes of today’s ‘disease diplomacy’ has not been a question of faith or belief as much as it has been of elastic iterability. Like the diseases it aims to combat, the Agenda aspires to travel unimpeded across borders.

How might one study such an object, if the question no longer becomes about belief and its political consequences? It is here that I find Caduff’s resistance to producing an exercise in the “hermeneutics of suspicion” both prudent and refreshing.[9] By refraining from an analytic bent on ‘debunking’ or ‘revealing’, Caduff is able to more carefully attend to “the complex and contradictory ways” that his ethnographic object appears (or fails to appear altogether), and in doing so, situates the possibilities within the science and politics of pandemic influenza. But it is here we might ask: when ‘security’ becomes dispensable, and the question is no longer about believing, but getting things done—what kind of analysis becomes possible? How might one resist the prophetic urge itself, a reliance on the “assumption that there is a truth that must be revealed” (Caduff 2015: 21)? I think it too early to declare, as the prophets do, “This is how it is…”.[10] In this regard, with Caduff (and James Ferguson) in mind, I would like to see more written today about the ‘uses’ rather than the ‘abuses’ of global health and its various projects, including global health security.[11]

It is clear, in any case, that Caduff’s book shows us the generative and captivating force of the dramatic and prophetic in this realm of public health preparedness; in many instances disbelief suspended almost indefinitely by those forecasting the always-already pandemic event. Caduff’s detailed analysis of the sites, practices, and poetics of scientific authority and claim-making, in and through both uncertainties and indeterminacy, is uniquely insightful and compelling. His attentive, detailed, and discerning ethnography performs its own variety of dramatic work—the text itself is a delightful and gripping read. It is both an erudite collection of insights about that which goes into and makes up the contemporary world of ‘scientific prophecy’. Caduff no doubt goes far beyond his modest aims to “see like a scientist”, offering a surplus of generative ideas and his own brand of “creativity and complexity” in thinking through the politics of pandemic preparedness—today a domain that often appears at least as fragile as the vision of a threatened ‘humanity’ it intends to protect.

 

References

Caduff, C. 2014.  “On the Verge of Death: Visions of Biological Vulnerability.” Annual Review of Anthropology 43(1): 105–121.

Calain, P., and C. Abu Sa’Da.  2015. “Coincident Polio and Ebola Crises Expose Similar Fault Lines in the Current Global Health Regime.” Conflict and Health 9(1): 1–7.

Collier, S., and A. Lakoff, eds.  2008.  Biosecurity Interventions: Global Health and Security in Question. New York: Columbia University Press.

Hoffman, S. J.  2010. “The Evolution, Etiology and Eventualities of the Global Health Security Regime.” Health Policy and Planning 25(6): 510–522.

Lachenal, G. 2014.  Ebola 2014. Chronicle of a Well-Prepared Disaster. Somatosphere, October 5, 2015.

Lakoff, A.  2010.  “Two Regimes of Global Health.” Humanity: An International Journal of Human Rights, Humanitarianism, and Development 1(1): 59–79.

Maguire, M., C. Frois, and N. Zurawski.  2014.  Anthropology of Security: Perspectives from the Frontline of Policing, Counter-Terrorism and Border Control. London: Pluto Press.

Masco, J.  2014.   Theater of operations: national security affect from the Cold War to the War on Terror. Durham, N.C.: Duke University Press.

Moon, S., D. Sridhar, M. A. Pate, et al.  2015.  “Will Ebola Change the Game? Ten Essential Reforms before the next Pandemic. The Report of the Harvard-LSHTM Independent Panel on the Global Response to Ebola.” The Lancet, November 26, 2015.

Morrison, J. S.  2014.  The Global Health Security Agenda: A Snowy Promising Start.

Rabinow, P.  1999. French DNA: Trouble in Purgatory. Chicago: University of Chicago Press.

Rushton, S.  2011. “Global Health Security: Security for Whom? Security from What?” Political Studies 59(4): 779–796.

 

Notes

[1] It is important to add that recent increased dialogue has occurred between the US offices spearheading the GHSA (particularly the National Security Council) and the WHO, who have recently developed the “Joint External Evaluation Tool”—a monitoring and evaluation framework that combines IHR compliance metrics with GHSA-related targets. Even so, the GHSA appears in this document only through implicit reference.

[2] http://csis.org/publication/global-health-security-agenda-snow-promising-start

[3] See the recent joint Harvard-LSHTM Ebola report, Moon et al. (2015).

[4] http://limn.it/introduction-ebolas-ecologies/

[5] See Lachenal 2014, Hoffman 2010, Calain and Sa’Da 2015, Rushton 2011; Masco 2014.

[6] Such criticisms have been rebutted by pointing to the fact that the GHSA today is endorsed and managed by a large number of both developing and developed countries. The Steering Group, for instance, is made up of country representatives from Canada, Chile, Finland, India, Indonesia, Italy, Kenya, the Kingdom of Saudi Arabia, the Republic of Korea, and the United States.

[7] For an overview of the large funding increases in the United States around issues of ‘health security’, see Boddie et al. 2015, Federal Funding for Health Security in FY2016. Health Security, 13(3): 186-206.

[8] In fact, Susan Erikson’s recent piece here in Somatosphere on the “Financialization of Ebola” details very succinctly what large changes are happening at the World Bank in this regard: http://somatosphere.net/2015/11/the-financialization-of-ebola.html

[9] Originally coming from Rabinow’s discussion at the end of French DNA (1999), pp. 173.

[10] For a review of anthropological engagements with apparatuses and ‘scapes’ of security, see Maguire (2014).

[11] For a great example, see Alex Nading’s recent piece in Limn: http://limn.it/ebola-chimeras-and-unexpected-speculation/. See also Collier and Lakoff 2008; Lakoff 2010.

 

Raad Fadaak is a PhD candidate at McGill University, working with the Departments of Anthropology, Social Studies of Medicine, and the Global Health Programs. His PhD research focuses on the projects and policies designed by governments, global health institutions, and international agencies to prepare for, respond to, and recover from public health emergencies.


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  1. Pingback: Book Forum––Carlo Caduff’s The Pandemic Perhaps by Todd Meyers - Bioethics Research Library

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