Health & Place 18 (2012) 695–700

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Health & Place

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Guest Editorial

Infectious Insecurities: H1N1 and the politics of emerging infectious disease

a r t i c l e i n f o

Keywords:

Health security

Swine flu

H1N1

Biosecurity

Securitization

92/$ - see front matter & 2012 Elsevier Ltd. A

016/j.healthplace.2012.01.004

a b s t r a c t

Responses to the 2009 H1N1 pandemic, and criticisms of those responses, were framed by issues

endemic to the meeting of ‘health’ and ‘security’ as governing domains. Offering an editorial

introduction to the selection of papers in this special issue, it is suggested that existing scholarship

in the emerging field of ‘health security’ can be categorized according to realist-advocacy, historical-

analytic, problematization and critical-inequality approaches. In contributing to this literature through

an event-based focus on the pandemic, the papers embrace the opportunity to examine health security

architectures acting and interacting ‘in the event’, to not only speculate over the possible implications

of this governing trope, but to review them. Questions of the scales of governance and associated forms

of expertise, the implications of differing modes of governance (from preparedness to surveillance to

forms of intervention), and the role of health inequalities in the patterning of the pandemic are

identified as key themes running across the papers.

& 2012 Elsevier Ltd. All rights reserved.

1 As Fidler (2003) argues, different concepts of security create different visions

of health security, and what came to dominate the approach adopted in the US

was a very particular form of security theory, that Fidler terms ‘the Realpolitik

Perspective’. This understands national security to be achieved through the

maintenance of military and material power, and has had significant implications

for the understanding and practice of health security responses to EID.

1. Introduction: health meets security

y it is increasingly y a matter of being governed by emergency,

in ways that inscribe the logos of war into the logos of peace via

the discourses of security that now proliferate throughout the

politics of ‘life itself’ (Dillon and Lobo-Guerrero, 2009: 17).

The dangerous intermingling of human, animal and viralecologies at unprecedented scales and highly pressurized vulner-abilities has produced the spectre of an emerging infectiousdisease (EID) of epic proportions, which threatens to be bothradically accelerated and rapidly distributed through the globalcirculations associated with agriculture, trade and travel. Policy,media and public concern over EID were thrown into sharp reliefby the 2009 global outbreak of swine-origin influenza A H1N1virus (variously also Swine, Mexican, North American or Califor-nian ’flu). The H1N1 pandemic highlighted global interconnected-ness through both the networks of disease distribution and theglobal range of biosurveillance, pharmaceutical markets andglobal health governance. It crucially also brought to the foreissues of place-based inequalities exacerbated through unequalaccess to medicines and response capabilities. Critically, however,the 2009 H1N1 pandemic did not just involve the colliding of themicrobial world with the domain of health governance, but of twodifferent regimes of governing – of health and security.

A growing body of scholarship across a number of disciplinesinterrogates the emergence of EID as a pre-eminent health con-cern and the convergence of this with contemporary securitydiscourses (Aldis, 2008; Brown, 2011; Cooper, 2006; Davies, 2008;Elbe, 2005; Fidler, 2003; Ingram, 2005; King, 2002; Lakoff andCollier, 2008). Within what can only be understood as a loosely

ll rights reserved.

grouped ‘health security literature’, a number of overlappingtrends can be identified. First, realist-advocacy approaches arguethat infectious disease must be recognized as a threat to nationalsecurity and responded to within the domain of security. Thebroadening of security studies in the 1980s and 1990s added EIDtogether with other nonmilitary issues such as food and ecologicalsecurity to the list of threats to national security, a domaintraditionally focused on external military threats to a country’sinterests, security and survival (Fidler, 2003).1 Together withgovernmental and non-governmental analyses and publicationsby journalists, think-tanks and institutes, this literature attemptsto reach and influence security policy audiences, particularly inthe US, in a pragmatic strategy to make public health relevant tothe agenda of decision-makers by elevating it to the high politicsof national security (Ingram, 2005; see Fidler, 2003 for a summaryof key reports, publications and outputs). There is also a wealth ofmore popular work on the threat of infectious diseases, includingjournalist pieces and book length tracts such as Mike Davis’s(2005) ‘The Monster at Our Door’ and Laurie Garrett’s (1996) ‘The

Coming Plague’. This combined literature has been instrumental inboth defining the focus of health security on communicablediseases transmitted through both intentional acts of bioterrorismby rogue states or terrorists and by unintentional spread (McInnesand Lee, 2006), and in the case of the popularist pieces, in

2 As Kittelsen (2007) argues, however, security itself also changes in its

meeting with infectious disease, as new domains of expertise, new modes of

enforcing borders, and new practices of intervening in the lives of the population

become part of the security matrix.

Guest Editorial / Health & Place 18 (2012) 695–700696

generating an increasingly high-pitched sense of threat andurgency. As Fidler (2003:856) argues, however, communicabledisease was put on the agenda in a way that much of the literaturehad not anticipated, as the move to the ‘high politics’ of securityled to a recentering of state self interest, with broader implicationsfor public health governance: ‘The anarchical structure and

dynamics of international politics constitute a virus to which public

health is not immune when health and security converge’.

Second, an overlapping current of work adopts an historical–

analytical approach to chart the meeting of health and security,the rise of concern and attention, and the influences, institutions,events and key players that pushed EID into the framework ofsecurity. These historical approaches can be either realist orconstructivist, with the latter focusing on the emerging dis-courses and processes of discursive construction defining ‘healthsecurity’, EID vulnerability and concern (Brown, 2011). Much ofthis work is geographically focused on the activities of the US orthe global health governance ambitions of the World HealthOrganization (WHO) and the development of the InternationalHealth Regulations (Andrus et al., 2010; Fidler, 2004; Hoffman,2010). Hoffman (2010), for example, identifies four periods ofglobal health security governance, the current distinguished bythe hegemonic leadership of the WHO, the primary actor inconstructing the emerging discourse of infectious disease secur-itization (Davies, 2008). The reframing of health issues frommatters of domestic public health and international develop-ment, to an imminent threat to international peace, stability andsecurity, is seen to be a consequence of a number of factors.These include the wider geopolitical context of post-Cold Warglobal governance concerns and the global security frameworkushered in by 9/11, with particular concerns centering aroundbioterrorism following the US anthrax attacks in 2001 (Davies,2008; French, 2009; Ingram, 2005; King, 2002, 2003; McInnesand Lee, 2006); the production of new transnational diseasethreats and interconnectedness through globalization, withstates less able to secure their borders through traditionalquarantine approaches (Brown, 2011; Budd et al., 2011; Fidler,2004; Hoffman, 2010); and the fanning of concerns through aseries of ‘focusing events’, outbreaks of microbial pathogensincluding SARS, avian influenza, West Nile virus and Ebola virusdisease, which demonstrated that infectious disease was not justa concern of distant others, but had the potential to impactwestern state’s economic and political stability and their citi-zens’ health (Ali and Keil, 2008; Collier and Lakoff, 2008; Davies,2008; Davis, 2005; McInnes and Lee, 2006).

Third, a body of work adopting a ‘problematisation approach’

review the ways in which securitization processes operate,identifying the rationalities and technologies of health securitywhose import into the domain of health is shifting the way inwhich infectious disease response is imagined, justified andconducted (Aldis, 2008; Brown, 2011; Lakoff and Collier, 2008).Not only is this apparent in the discourses of urgency and threatthat cloak discussions of EID allowing governance through statesof insecurity (Brown, 2011; Lentzos and Rose, 2009; Lo Yuk-Pingand Thomas, 2010), but also in the re-alignment of the temporaland spatial scales of health governance (Collier and Lakoff,2008), the adoption of new forms of surveillance and informa-tion management (Fearnley, 2008; French, 2009; Parry, thisissue), and the justification of new modes and technologies ofintervention and containment. Lentzos and Rose (2009:231)distinguish securitization as entailing ‘border controls, regimes

of surveillance and monitoring, novel forms of individuation and

identification, notably those based on biometrics, preventative

detention or exclusion of those thought to pose significant risks,

massive investment in the security apparatus and much more.’

Critically, work within this area has identified the governance of

the future as a distinguishing feature of securitization(Anderson, 2010a, 2010b; Caduff, 2008). This includes discoursesand practices through which future events are rendered think-able and constituted as problems (Collier and Lakoff, 2008;Lentzos, 2006), technologies of futurity (Fisher and Monahan,2011), and future orientated configurations of anticipation,contingency planning, preparedness and pre-emption (Lentzosand Rose, 2009). Davies (2008) argues that this future-orientatedperspective does not go far enough, however, as health securitymechanisms focus on preventing contagion through enhancedsurveillance processes, rather than in preventing the conditionsfor the emergence of disease in the first place. While Davies(2008) suggests that securitisation locks agents into the logic ofdefining a referent object and an external threat source, Lentzosand Rose (2009) suggest that norms and threats are establishedthrough patterns, regularities and irregularities (stochastic var-iations) of flows. Taken together, developments in the discourseand practice of security are profoundly impacting the govern-ance of health.2

Finally, critical-inequality approaches highlight the widersocial, political and economic implications of the securitisationof health, particularly in terms of the compounding effects ofmultiple inequalities (Sparke, this issue; Sparke, 2010). Themeeting of security and health is shown to have occurred insuch a way that privileges security, as attention, money andresources are redistributed (McInnes and Lee, 2006). At theglobal scale the WHO has seen a shift from the universalistright-to-health ideology of its first five decades, to an over-ridingconcern with the management of infectious disease, represent-ing the strategic interests of western nations (Fidler, 2003). Thisdomination of the global health agenda by health security isleading to a broader ‘securitization of health’, with public healthinitiatives justified as defensive measures against threat ofepidemics or biological terrorism (Hoffman, 2010). For publichealth infrastructure in US, Ingram (2005:533) argues that thishas ‘led to a narrowing of focus, excessive specialization, constraints

on science, and massive misallocations of resources and opportunity

costs’. This analysis applies equally to developing countries, theperceived ‘reservoirs of disease’ (Brown, 2011; Hoffman, 2010),who additionally suffer multiple compounding inequalitiesstemming from poverty and unequal access to resources, ashealth security tends to ‘the fears of the rich rather than the needs

of the poor’ (Brown, 2011:324).If ‘public health security’ defines policy areas in which

national security and public health concerns now overlap andhas had profound implications in the domain of practice (Fidler,2003), it also offers opportunities for creative and generativesynergies between critical academic fields. Beyond the literatureon health security, a burgeoning field of scholarship acrossgeography, anthropology, sociology and the political sciences isengaged in exploring the wider securitization of the life-world.This includes attention to the biosecuring of agricultural andenvironmental ecologies, questions of biosafety, containmentand laboratory ethics, and concerns over new biotechnologiesand innovations, such as genetic modification and nanotechnol-ogy. This work is informed by and driving a number of theore-tical currents, including, although not exclusively, interests ingovernmentality and biopolitics (Braun, 2007; Collier et al.,2004; Cooper, 2006; Dillon and Lobo-Guerrero, 2009; Collierand Lakoff, 2008); questions of risk, uncertainty and indetermi-nacy (Donaldson, 2008; Fish et al., 2011; Hinchliffe, 2001);

Guest Editorial / Health & Place 18 (2012) 695–700 697

attention to nonhumans and coproduced networks, mobility andagency (Ali and Keil, 2008; Barker, 2010; Braun, 2008; Clark,2002; Wallace, 2009); the interrogation of spatial processes ofcategorization and boundary-making (Barker, 2008; Donaldsonand Wood, 2004; Mather and Marshall, 2011; Tomlinson andPotter, 2010); and geopolitical concerns with the interactionbetween nation states, processes of globalization, postcolonialismand modes of inequality (Farmer, 1999; French, 2009; Ingram,2005, 2009; King, 2002, 2003; Sparke, 2009). These diversetendencies together demonstrate that no single theoretical lens issufficient to fully encapsulate and respond to the critical issuesraised by the predominance of the EID worldview.

2. Interrogating H1N1

‘The virus writes the rules. And it can change them at any timey’

(Chan, 2009).

It is in this context that the special issue considers theimplications of the securitization of health by focusing on the2009 outbreak of swine-origin influenza A H1N1 virus. What canattention to one disease event hope to bring to this literature andour understandings of security responses to EID? In some ways,crucial theoretical developments and new areas of enquiry haveproceeded in a disease-driven way. HIV-AIDS, for example, hasarguably marked the literature through attention to geopoliticalconcerns over the place of health in global governance as well asthrough questions of inequality (Elbe, 2005; Ingram, 2009);scholarship emerging from reflections on the SARS epidemic drewattention to the globalised co-produced networks of diseaseexchange (Ali and Keil, 2008; Braun, 2008; Fidler, 2004); andhighly pathogenic Avian flu has, through its construction as ‘thenext big thing’ highlighted the future temporalities of diseasegovernance, what Samimian-Damash (2009) refers to as the ‘pre-event configuration’, the constellation of anticipatory discoursesand practices (Bingham and Hinchliffe, 2008). What will ourreflections on H1N1 contribute to this field?

In many ways H1N1 has been a test of health security; of theglobal and national architecture of surveillance and influenza pre-paredness planning developed and strengthened in the wake ofSARS (Fidler, 2004). It has also revealed its limits, particularlythrough the influence of this architecture over the resulting pan-demic event. Drawing together debates in public health andinfectious disease management with work on biosecurity and widerattention to securitisation, the papers in this special issue go beyondmarking the novelty of infectious disease emergence and spread andresultant security practices, by interrogating the implications of thehealth security configuration through a sustained engagement withits operation during the pandemic. H1N1 offers the opportunity toconsider the modalities of health security governance during theevent of an outbreak, to not only speculate on the possible implica-tions of this governing trope, but review them.

In particular, the papers raise three issues that emerge ascentral to this meeting of security and health in the context ofH1N1: questions over the scale of governance and attendantspatio-temporal forms of expertise; the ‘eventual’ implicationsof new modes of preparedness, surveillance and intervention; andthe emergence of new and differing forms of inequality.

2.1. Scales of governance and spatio-temporal forms of expertise and

intervention

‘Vulnerability is universal’ (Chan 2007: vi, quoted in Brown,2011, p. 321)

H1N1 threw into sharp relief issues of scale and spatialpractices connected to the governance of EIDs. The WHOannounced the global pandemic and international pharmaceu-tical responded; national preparedness plans were invoked;national populations were threatened by cross-border foreignbodies (human, animal and microbe); regional health protec-tion agencies coordinated with the national centre; local andurban level health authorities struggled for differentiation; andindividuals were contained and pre-emptively medicated forthe national interest. The question of scales – the correctspatial scale of governance, the temporal scale of interventionand action, and the appropriate scale of the response – runsthrough the papers.

Much existing work that engages with the different scales ofgovernance in the response to EID considers the geopoliticalinteractions between western and non-western nations, andattempts to overcome the ‘obstacle of sovereignty’ by providingauthoritative power in infectious disease governance to the WHO(Davies, 2008:313; Fidler, 2003). Davies (2008) has argued thatthe Global Outbreak and Alert Response Network (GOARN) andthe revision of the International Health Regulations (IHR) demon-strates the WHO’s attempt to retain its authority in global healthgovernance and centre itself within a justification for a globalresponse to disease. The papers in this special issue move beyondthese particular geopolitical interactions to consider how thefixing of H1N1 as a health security event itself produced tensionsthrough the conflicting spatialities of health governance andsecurity practices. This begins to address the comparative lackof attention to questions of health security at local–regional–national dialectics, in comparison to the wealth of work on thegeopolitics of health and security at national–internationaldialectics.

While Birmingham, for example, became a ‘hotspot’ for theH1N1 pandemic in England, this spatial differentiation wasignored in the fabrication of a national epidemiological unitthrough attempts by the national administration to homogenisethe response at the national level (Chambers et al., this issue).Bronwyn Parry (this issue) takes these questions into a com-parative discussion of individual and population-level biosur-veillance in operation in the US and UK. Through the unificationof these scales, more robust and finely calibrated systems ofbiosurveillance are being constructed and imagined, she argues,which allow for the identification and containment of possiblesick individuals. Infectious diseases therefore not only challengethe boundaries of regulatory jurisdictions, but the interaction ofdifferent scales of governance.

Through pressure for national level governance and leader-ship around epidemic scenarios, the governance of diseasebecomes part of broader processes of place, nation and worldmaking (Ingram, 2009; Stephenson and Jamieson, 2009). Adesire to construct the UK as the European country bestprepared for the pandemic (and so civilized, rational, well-controlled) influenced the scale of the English administration’sresponse to the H1N1 pandemic (Barker, this issue). As MatthewSparke highlights, however, the place-making geographies ofdisease can also work to reinforce inequalities through thecultural and economic ostracisation of peoples and placesthrough powerful outbreak narratives, which ‘give microbes a

natural history in the primordial landscape of the developing world’

(Wald, 2008: 46, in Sparke). Whilst drawing out lessons for theimplications of pandemics for shared vulnerability of human,animal and viral ecologies, Sparke urges attention to this asym-metric inequality amidst interdependency, the place-based var-iations in blame, risk, surveillance and response capacity, andcrucially the experience of illness.

Guest Editorial / Health & Place 18 (2012) 695–700698

2.2. Modes of preparedness, surveillance and intervention

No mass of information will help us pinpoint the precise when,

where and how of the coming havoc. We can only speculate

(Cooper, 2006:119).

The papers question the assumed relationship between therationalities and technologies of preparedness, surveillance andintervention, and the reduction of the social, economic andbiological disruption of disease. The generation of the H1N1 eventwas not just a result of the relationship between the virus,vulnerable human bodies, and international transportation net-works, but also an outcome of the highly sensitized globalsurveillance and preparedness apparatus and its underdevelopedcapabilities to act in a reduced capacity in the event of a mildpandemic (Barker, this issue). This goes against the very logic ofpreparedness, which attempts to prevent the wider disruptiveeffects of events through permanent institutional readiness. ForH1N1 in most affected countries, the impacts of containmentpolicies were greater than the mild profile of disease. In thecontext of the UK Chambers et al., this issue discuss interventionsthat they argue went beyond the evidence base. They highlightthe prophylactic use of tamiflu, the effects of school closure andthe implications of diverted health care funds as particular causesfor concern.

The H1N1 saga was in many ways defined by questions ofsurveillance and wider issues of information production andmanagement. While Parry draws attention to the potentialdangers of the extension and naturalization of surveillance ineveryday life, and Barker highlights the contribution of surveil-lance to the production of events, Chambers et al., this issuequestion the utility of this informatic hologram of the event forthe actual business of response management. Despite a wealthof information continuously churned out by government, tradi-tional and new media sources, laboratories and policy forums,information-visibility at a local governance level was in manycases poor, as the epidemiological picture was built at theregional level.

For Parry, the question of information utility is oversha-dowed by the information-generating capacity of the biosur-veillance apparatus and the possibilities for its malevolent use,as data from everyday or private contexts becomes enrolled inthe broader agenda of the security state. This poignantly high-lights the importance of academic and community vigilanceover the uses of technologies that facilitate biosurveillance evenin benign and liberal political contexts. As epidemiology isincreasingly mapped through ever more complex and immedi-ate forms of infodemiology3 (Eysenbach, 2009), privacy, repre-sentation and control become part of its constellation ofconcerns.

Finally, Brigitte Nerlich and Nelya Koteyko consider commu-nication about pandemic communication itself, in newspaperarticles and online blogs, to address a range of questions relatedto the role of the media, official panic, blame, fear and hype(Nerlich and Koteyko, this issue). They identify what they term as‘self-blame’ in the reflections of segments of the media over theirrole in fueling emotive responses to pandemics and pandemicwarnings, and suggest that a form of ‘digital democracy’ throughnew media sources has opened up spaces for discussion anddissent in the public sphere. However, they warn that this climate

3 Infodemiology and infoveillance are terms coined by Eysenbach (2009) to

describe the way in which electronic information generated through internet use

(such as Google searches, social media status updates, or automatic searches of

news stories) can be used to inform health security responses. Here the term is

extended to include other forms of information that signal individual health

status, which can be enrolled in the visualizing and response to pandemic events.

of self-reflexive blame and counter blame discourses may not beconducive for ‘fostering vigilance while allaying fears’ (Briggs,2010).

2.3. New/differing forms of health inequalities

The landscape of political insecurity is not fully congruent with

the landscape of need (Ingram, 2005:539).

The initial identification of H1N1 in the vulnerable bodies ofMexican rural poor living in proximity to a large American ownedswine processing plant gave us some early hints of the multiplestructural inequalities driving and reinforced by the pandemic.Sparke traces this ‘epidemiology of inequality’, highlighting theimplications of inequalities in blame, of unequal risk manage-ment, of response capacity and of medicine access, on thestruggling public health systems of the developing world. Sig-nificantly, he highlights the ways in which existing forms ofinequality gave rise to the emergence of the ‘flu virus, which thenacts to compound and produce new forms of inequality.He pushes our understandings of the impact of inequality onill-health and disease away from simply treating it as an in-dependent variable, to a recognition of structural dynamics thatco-produce inequality and negative health outcomes. For EIDs, thissignificantly includes cutback in health services, privatization,structural adjustment policies, industrialized meat productionprocesses and cross-border labour insecurity.

But this is much more than a story of an emerging EIDstemming from, and disproportionately afflicting the poor of theglobal south. As the globally-framed health security concerns ofthe privileged west divert attention from more lethal yet every-day threats of poverty, dirty water and malnutrition, healthsecurity and health become conflicting aims. Yet this fundingmisallocation affects not only malaria sufferers in Nigeria, butalso teenage mothers in Birmingham (Chambers et al., this issue).Cross-border exchanges of dangerous polluting industries and‘risky bodies’ between Mexico and the USA demonstrate contrast-ing levels of opacity in the origin and blame stories of the globalmedia, yet it is also front-line health care providers in the US whobecome subject to biosurveillance and enforced vaccination(Parry, this issue). And the exploitative commodity productionchains of neoliberal globalization are shown to produce bothglobal health insecurity and local labour insecurity; environmen-tal ‘bads’ and bad food; and emerge as the most fertile breedinggrounds for both pathogens and pathogenic inequality (Sparke,this issue).

3. Final Thoughts

‘[H]ow [does] couching concerns through the language of security

and the accompanying rationales that follow construe the under-

standing of what is happening and what is possible?’ (Rappertand Gould, 2009: 14).

Taken together, the papers in this special issue consider, fromdifferent angles, how and why the modalities of security come tothreaten the values they seek to protect. By challenging ourassumptions over the meanings of security and insecurity, theyhighlight the political and ethical challenges of living with risk,threat and uncertainty. They attempt to go beyond the criticism ofthe securitization of health, to consider what a pandemic eventcan reveal about the technologies and rationalities of healthsecurity as it interacts with the wider discourses and orderingsin which it is embedded.

Many questions remain. What can the relationship betweenpublic health and health security tell us about the connectionsbetween security and modes of governing in other domains? How

Guest Editorial / Health & Place 18 (2012) 695–700 699

widely do we need to re-imagine the production of vulnerability toEID, and what does this mean for both the systems of response andour responses to those systems? In what ways do our analyses of theEID worldview perpetuate a ‘hermeneutics of suspicion’ for all modesof securing health and EID (Haggerty, 2006), and how can weenvisage and enact better ways of living in an insecure world?

H1N1 was, we now know, a mild virus, which rendered and madevisible the practices and discourses of health security in particularways. This does not make H1N1 a non-event, or even the dressrehearsal for a future, more severe pandemic. What it does offer is theopportunity to examine health security architectures acting andinteracting ‘in the event’ without the multiple cloaking tragedies amore virulent virus would inevitably bring. Infectious Insecuritiesrefers to this world in which emerging infectious disease is dominat-ing public health governance concern. It also reflects the seeminglyinfectious nature of these security modalities themselves.

Acknowledgements

The papers in this special issue were first presented at theseminar ‘Conceptualising Biosecurity: the Case of Swine Flu’ heldat Keele University in December 2009, the first of five seminars inthe series ‘The Socio-Politics of Biosecurity: Science, Policy andPractice’, funded by an ESRC seminar series grant (see www.bbk.ac.uk/environment/biosecurity). Many thanks to my co-organi-sers Andrew Dobson and Sarah Taylor, and to all the seminarparticipants, for good humour and energetic discussions.

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Kezia BarkerDepartment of Geography, Environment and Development Studies,

Birkbeck, University of London, UK

E-mail address: k.barker@bbk.ac.uk

Received 1 November 20113 January 2012

16 January 2012