Further reflections on “Two Regimes of Global Health”: On the elision of distinctions

Let me begin my post with a question raised by Humanity editor Nils Gilman (who blogs at Small Precautions). Nils asked: I’d be interested in hearing you elaborate on what you think the political implications are of the distinction between “humanitarian biomedicine” and “global health security” – or rather, more specifically, on the tendency of policymakers and public health officials to elide the distinction in much public discourse of “global public health.”


That the two very different formations (defined below, and in more detail in the article) are often elided seems to me a result of the contemporary status of “global health” as a term that connotes moral virtue, that is ostensibly independent from politics, and that therefore is able to garner support from various kinds of sources – not only public health agencies, but also development agencies, humanitarian organizations, religious groups, and prominent philanthropists.


This elision masks some crucial distinctions in the politics of health, for example in answering these basic questions: Which diseases should be targeted? Who should be protected from these diseases, and how?


Global health security emphasizes outbreaks of disease that have not yet occurred, but that pose catastrophic threats to the functioning of critical systems. It sets up alert systems that are global, but its response systems remain resolutely national; and so resources for medication stockpiles, for vaccine contracts, for distribution systems, for hospital surge capacity, and so on are limited to the wealthy world.


Biomedical humanitarianism, in contrast, targets already-existing diseases that in places that have poorly functioning public health systems – exemplary sites are sub-Saharan Africa or Haiti. It seeks to transcend national boundaries and to treat suffering individuals directly. However, although many of the conditions it seeks to treat are chronic, it has difficulty in sustaining its interventions over time because it relies on donors who are moved to respond to acute emergencies.


If the danger for biomedical humanitarianism is that neglect will return as soon as the visible emergency moves to a different place (as Peter Redfield has argued), the danger for global health security may be one of over-preparedness – that its credibility is damaged when it responds to an event that turns out not to be as catastrophic as promised.


The recent global response to swine flu (H1N1) is instructive.  have recently demanded to know why billions of euros were spent on a disease that turned out to be less deadly than seasonal flu. They’ve accused the World Health Organization of complicity with the pharmaceutical industry in overhyping the threat. I think this criticism misses the point. As soon as H1N1 entered an existing global health security apparatus public health authorities and politicians had no choice but to act prudently.


The apparatus had been constructed in preparation for the onset of a different type of influenza: an easily transmissible strain of bird flu (H5N1). Global disease surveillance systems were in place; emergency operations centers were ready; wealthy countries had stockpiled anti-viral medication and had advanced contracts in place with vaccine manufacturers; national and local pandemic plans had been developed and exercised. The apparatus was put into action by national governments as soon as a pandemic was declared.


On the other hand, if the disease had in fact been as catastrophic as initially feared, something else would have become tragically visible: the very narrow purview of global health security. The stockpiled medications, the vaccine production contracts, and the counter-measure distribution systems were by no means “global.” Meanwhile, biomedical humanitarianism would not have had the capacity to treat those left out of the circuits of global health security.

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About Andrew Lakoff

Associate professor of anthropology, sociology, and communication at the University of Southern California. His first book, Pharmaceutical Reason: Knowledge and Value in Global Psychiatry (2005), examines the role of the global circulation of pharmaceuticals in the spread of biological models of human behavior; it is based on research conducted in Argentina, France, and the United States. His current research concerns global health and biosecurity and includes his coedited volume Biosecurity Interventions: Global Health and Security in Question (2008) as well as his edited volume Disaster and the Politics of Intervention (2010).

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