17.2: What Are Health and Health Security?

This section provides an overview of the concept of health and its determinants to set the stage for an introduction to the concept of health security. We provide an overview of key terminology and discuss the implications of health security in relation to health not only as an outcome, but in terms of its broader determinants.

Health and Its Determinants

Health refers to “a state of complete physical, mental and social well-being, not merely the absence of disease or infirmity” (WHO, 1948, p. 1). Health is therefore both a state, outcome and process that plays out at the level of an individual (i.e. when we get sick or experience an injury), but also at the level of populations. Individual health is typically treated by health professionals across health and social systems of care, whereby health systems are typically considered a front-line response to protecting against disease population health (Kutzin & Sparkes, 2016). Preventative aspects of population-level health are the responsibility of public health—which, as a field of research, policy and practice, has the role of protecting and promoting health, preventing disease and injury, and reducing health inequities. Public health is therefore directly informed by the cross-disciplinary study of, but also practice and policy directed towards, population health and its determinants. Health is not only a product of individual choice and genetics, but is the direct result of social, political, economic and environmental determinants (Marmot 2009). These determinants of health modify and influence who bears the burden of a disease or chronic condition and the extent of the impact on both individuals and populations, and explain group differences in health status (Marmot, 2009; Mikkonen & Raphael, 2010).

Including the determinants of health in a conversation about health security is incredibly important. The determinants of health refer not only to the things which negatively influence our health over time, but also our adaptive capacity to respond to threats. By broadening our understanding of health beyond any single impact to recognize the broader context(s) of ill-health, we are able to connect health and security to questions of livelihoods, geopolitics, social relationships, and ecological systems. For example, a modelling study estimated the cost of a hypothetical infectious disease outbreak to be between $13 million to $64 million for one country, to $8 billion to $41 billion for nine countries, placing between 1500 to 1.4 million export-related jobs at risk (Bambery et al., 2018). Not only does an infectious disease pandemic therefore impact individuals and populations in terms of their health, but it will also affect the systems of care treating those affected, and have massive economic impacts that may slow economic development at best, or threaten economic and regional destabilization at worst, ultimately influencing the security of a population to afford the basic necessities of life (Cameron, 2017). Thus, health in a security context, must necessarily account not only for health-related outcomes, but also the features that determine, modify or mediate those outcomes.

Health Security: Overview and Challenges

According to McInnes (2015, p. 7), there are “… four terms widely used in debates over health security in the global context…global (public) health security, national security, human security and biosecurity” and that they are not synonymous, reflect different interests and agendas, and have different implications for how we understand the health and security nexus (Lo Yuk-ping & Thomas, 2010). National security typically refers to securing the borders of a country and the welfare of the citizens within its bounds. Biosecurity is a field of study intended to protect humans, plants and animals against harmful biological agents, and in some contexts such as New Zealand, has been interpreted to include entire ecosystems. Human security, as outlined throughout this text, and as defined by the United Nations, is an approach for “identifying and addressing widespread and cross-cutting challenges to the survival, livelihood and dignity of their people” (UN General Assembly Resolution 66/290, Article 3, p.1). Related to each of these three concepts is the notion of health security or global public health security which are often used interchangeably.

For example, let us briefly return to the WHO constitutional mandate for achieving health for all through security and peace. In this context, and as articulated by Aldis (2008, p. 370), “’security’ seems to refer to ‘health and security’ (the contribution that health makes to global security) rather than to ‘health security’ (securing health itself).” Importantly, there seem to be no universally agreed upon definitions for health security (Lee & McInnes, 2004; Rushton, 2011). There are, however, several recurrent themes across the health and human security literatures emerging from a published literature review, which include:

• Protection against threats (e.g. disease, poverty, oppression, hunger, etc.)
• Emergence of new global conditions under which past approaches produce diminishing returns (e.g. rise of failed states, emerging environmental threats, etc.)
• Engaging new allies (e.g. public health collaboration with military establishments)
• Linking health to foreign policy interests (e.g. HIV/AIDS pandemic as a national and international security threat).^[1]

Following Lee and McInnes (2004), a global health issue can rise to prominence on international security agendas if it is international in scope, threatens economic destabilization, impacts the stability of a region, and/or when health issues are part of trade negotiations. Feldbaum and Lee (2004) similarly highlight that a global health security threat typically impacts populations of people rather than individual health, produces a high incidence of death or disease, produces acute rather than long-term or chronic health impacts, and are experienced by more than one country. Much of the health security literature echoes these criteria, whereby extreme threats of international proportion establish legitimacy for a substantial political response.

Indeed, the discourse of health security dates back centuries as a reflection of historical disease outbreaks, more recently converging around the increasing importance of public health security in a highly globalized world (Kamradt-Scott, 2015; Novotny, 2007). Hoffman (2010) characterizes global health security according to four regimes:

1. Unilateral quarantine regulations (1377-2851)
2. A series of Sanitary conferences beginning in 1851 to develop international agreements around infectious disease response
3. The establishment of several international sanitary conventions and international health organizations (1892-1946)
4. Under the leadership of the WHO (1946-present).

This last regime which has been challenged by an increasingly globalized and interconnected world, recently culminated in The International Health Regulations (IHR) created by the WHO in 2005 and its member states (Kamradt-Scott, 2011; Katz et al., 2014; Kennedy et al., 2018; Paranjape & Franz, 2015; Wilson et al., 2008). Driven largely by the severe acute respiratory syndrome (SARS) outbreaks in Canada and China, but also increasing concerns over variations in pandemic influenza and heightened security concerns over terrorist activities, the IHR “aim to prevent, protect against, control and provide a public health response to the international spread of disease” (Article 2), with the intent of incorporating “biological, chemical and radio-nuclear events, as all as zoonotic diseases and threats to food safety” (Gostin & Katz, 2016, p. 267).

Thus, health security under the IHR encompasses not only traditional biological threats such as the spread of disease either naturally or otherwise, but also terrorist attacks (Eisenman et al., 2004; Khan, 2011), and nuclear and biological weapons (e.g. engineered pathogens or otherwise) (Carus, 2015; Colf, 2016). Perhaps overlooked elements of health security under the IHR may include human trafficking and other disease transmission pathways (Worsnop, 2019), antimicrobial resistance (Toner et al., 2015), mass migrations (MacPherson et al., 2007; Viettie et al., 2013; Zimmerman et al., 2011), and other so-called global catastrophic biological risks which include climate change and violent conflicts (Barnett & Adger, 2007; Percival & Homer-Dixon, 1998; Schoh-Spana et al., 2017; see also Chapter 5).

These trends reflect an increased focus on global governance in relation to health security, and how security discourses have become a dominant response to global health threats (Chen & Narasimhan, 2003; Fidler, 2007; McInnes, 2005). These developments have arguably led to a privileging of infectious diseases as central issues in the health security discourse (e.g. pandemic influenza, Ebola, HIV/AIDS, Zika), which has engendered a particular emphasis on improving global health surveillance platforms for data sharing, enhancing laboratory testing, workforce development, and promoting rapid humanitarian and emergency response (Balajee et al., 2016; Belay et al., 2017; Borchert et al., 2014; Fitzmaurice et al., 2017; Sikka et al., 2016; Tappero et al., 2017). This necessarily includes building effective systems of care and associated emergency management protocols in order for primary health care to be an effective contributor to health security and associated reactive and proactive responses (Chan, 2009). Indeed, local health departments play significant roles in responding to the immediate and longer-term recovery from health security threats, and require programming to support training, safety, public preparedness, planning for emergency response and evaluation (Errett et al., 2015; Taylor et al., 2018). Moreover, policy frameworks such as the IHR necessarily stress the importance of international collaboration and the need for diplomacy to achieve policy coherence that supports the promotion of health security in a rapidly globalizing world (Bond, 2008; Frieden et al., 2014).

Although these developments in health security bring new perspective through renewed foci on governance, conflict, diplomacy and disease, we find these approaches to health security and associated responses problematic for at least three reasons. First, much of what is outlined above is reactive in nature, rather than proactive in mitigating the risk of the threat to health security in the first place. A second concern is that these approaches to health security do not engage fulsomely or directly with our earlier definitions of health in relation to its broader determinants. A third, interrelated concern, is the growing need to address the converging implications of both social and ecological change for health security.

This last concern in particular has been raised by authors such as Ostergard and Kauneckis (2014) who examine research on climate change impacts to human health security. The overarching concern raised here is that the health security literature has tended to emphasise and exemplify acute events that create health emergencies, but larger, slower-moving emergencies such as global environmental change—which pose significant health threats, but also an existential threat to the human species—have typically been neglected. Instead, health security discourses seem to primarily respond to emergent implications of global environmental change such as changes in the distribution and patterning of disease vectors, or emergency response following extreme climate events (e.g. hurricanes), without adequate attention to preventing the upstream drivers of these threats. In the following sections we seek to rectify this shortcoming by drawing attention to converging social and ecological drivers of change influencing health security, through the fast and slow-moving influences on broader determinants of health.