BioWeapons Prevention Project

Introduction
One development in the Biological Weapons Convention (BWC) since the turn of the 21st century involves incorporation of public health directly into bioweapons policy. Experts involved in this incorporation have generally considered this shift to be helpful. However, with the Seventh Review Conference (RevCon) approaching, scrutiny of the BWC-public health relationship is in order because the convergence of these areas reflects weaknesses that limit its potential beyond the Seventh RevCon.

Public Health in the BWC Process
Public health’s incorporation into the BWC process began after the conclusion of the Fifth RevCon in 2002 through the intersessional meetings that took place before and after the 2006 Sixth RevCon. These meetings included sessions devoted to the importance of public health surveillance and response capabilities for bioweapons policy. Prior to this inclusion of public health, the BWC created friction with health interests in BWC parties that sought, under Article X of the BWC, access to technologies for working on biological agents for peaceful purposes. Difficulties with pharmaceutical and biotechnology industries in crafting a verification protocol from 1995 to 2001 also revealed tension between the BWC’s objectives and these industries’ health-related goals. These episodes reflected problems concerning public health within the BWC process, which helps explain why, historically, public health and bioweapons experts did not interact much. Before and after the BWC, no government mounted serious and sustained public health preparations for an enemy State’s use of bioweapons.

The BWC-public health relationship changed sufficiently by the Fifth RevCon to allow the BWC process to involve public health directly. The transformation that vaulted public health into the BWC’s world was bioterrorism. From Aum Shinrikyo’s sarin attacks in 1995 to the anthrax attacks in 2001, security and non-proliferation communities realized that public health surveillance and intervention capacities were critical to countering bioterrorism. The need to identify disease events, assess their origins, and respond to mitigate their consequences highlighted the contributions public health systems had to make to strategies against bioterrorism. The intersessional meetings on public health surveillance and intervention capacities after the Fifth and Sixth RevCons reflected BWC parties' awareness of the public health’s importance to addressing the changing threats from bioweapons.

The “Securitization” of Public Health
The heightened profile of public health within the BWC process represented one example of attempts to link public health with security, which included framing certain problems, such as HIV/AIDS and pandemic influenza, as security threats. Making public health a security issue gave public health political importance it never previously had, and this approach produced arguments premised on exploiting synergies between prevention and control of threats from bioweapons and naturally occurring infectious diseases. In other words, policies to strengthen defenses against bioweapons would also benefit efforts against naturally occurring infectious diseases, and vice versa.

Another example of the securitization of public health is the 2005 adoption by the World Health Organization (WHO) of the revised International Health Regulations (IHR), which, radically, included disease events related to biological, chemical, and radiological terrorism in addition to naturally occurring infectious diseases. For WHO, the IHR is an instrument that advances “global health security” through an all-hazards approach to disease events. Public health’s use of security arguments supported the BWC process’ incorporation of public health thinking, contributing to the momentum seen in the securitization of public health in the past decade.

Problems in Theory and Practice: The BWC and the Securitization of Public Health
With time and experience, problems have appeared in the new BWC-public health relationship that raise questions about its utility and sustainability. The threat of bioterrorism transformed this relationship, but, as this forum explores elsewhere, whether the BWC can adequately address bioterrorism remains hotly debated—putting public health’s incorporation into the BWC process into those contentious waters. The bioterrorist threat has also increased interest in biodefense, which has raised public health concerns—including more risk of biosafety accidents, biosecurity regulations that hamper scientific research, and allocation of resources for biodefense priorities of little to no help for public health. The BWC process struggles with the surge in interest in biodefense because the BWC permits biodefense research but has no mechanism to verify that such research remains within limits set by the treaty. Thus, unless something dramatic changes at the Seventh RevCon, the BWC process does not provide fertile space for public health concerns about the renaissance of interest in biodefense.

These concerns connect to growing skepticism about the synergies promised through the securitization of public health. Although some public health surveillance and response capabilities have benefited from securitization policies, events have revealed less potential for synergies than earlier asserted. In addition, available synergies have been exploited outside the BWC process through initiatives such as the revised IHR, the Global Health Security Initiative, and bilateral programs aimed at shoring up security-relevant public health capacities in strategically important countries. Discussion of public health in the BWC process does not harm these other efforts. However, whether BWC attention on public health has produced results independent of other security-public health projects, which do not depend on the BWC process, is not clear. This uncertainty raises questions about the need to use the BWC to mould the next phase of the securitization of public health. Problems encountered with pandemic influenza in 2009, such as mistakes made by WHO and lack of equitable access to vaccine, will not be resolved through BWC discussions about public health's contributions to bioweapons policies. Nor does the BWC offer much to efforts to address other disease problems linked with security concepts, including HIV/AIDS, antimicrobial resistance, and maternal and child health.

Mounting skepticism about the securitization of public health also echoes long-standing BWC problems. For many developing and least-developed countries, bioweapons and bioterrorism are far down their lists of public health priorities, which makes a BWC focus on public health appear to serve the interests of developed countries that worry about bioterrorism. This skewing of the BWC process towards the interests of more powerful nations connects to controversies that have stymied progress on Article X for years. The renewed push for biodefense also emanates mainly from developed countries, and, in the eyes of some experts, this push blurs the line between permissible biodefense and prohibited bioweapons development. This dynamic might heighten the reluctance of developing and least-developed countries to take the BWC process seriously as a means of bolstering their public health capabilities.

The Seventh RevCon and the Future of the BWC-Public Health Relationship
For the Seventh RevCon, consideration of public health's importance to BWC objectives constitutes "low-hanging fruit" because the BWC-public health relationship does not, as approached in the intersessional meetings and the Sixth RevCon, represent a particularly controversial topic that causes negotiating schisms among BWC parties. As low-hanging fruit, this issue will not determine the success or failure of the Seventh RevCon. With the securitization of public health pursued in many contexts outside the BWC, what happens with the BWC-public health relationship at the Seventh RevCon will also not alter significantly broader, continuing attempts to link security and public health. Game-changing developments, such as developed countries agreeing to increase public health assistance to developing and least-developed states under Article X, do not seem likely given fiscal problems many developed countries face now and in the foreseeable future. Thus, the Seventh RevCon will not affect much the future of the securitization of public health as an increasingly questioned strategy, except perhaps to agitate growing doubts about the policy wisdom of framing public health surveillance and response capacities as instruments of national security.

In his opening contribution to this discussion David Fidler set out clearly and succinctly the history of public health’s engagement with the BWC and linked this to a broader trend of the securitization of health. That securitization process has seen health come to be linked with traditional security issues such as BW, but has also seen naturally-occurring health ‘threats’ being increasingly framed in security terms by a range of actors. As Fidler rightly points out, the linking of public health to security – including but not only through BW policy - has been seen by some as an opportunity to attract increased political attention and resources for health. Others have been concerned about possible negative side-effects, fearing that health goals may become subjugated to narrow (and predominantly Western) security priorities. At the heart of this debate is the question of whether security and public health can have a mutually beneficial relationship, or whether there is a risk of health efforts becoming distorted by the security agenda.

The incorporation of public health capacities (for example disease surveillance infrastructure and emergency response capabilities) into the BWC is a particularly clear example of securitization: public health has taken on a role in what is effectively an arms control exercise. Further progress down this road could potentially, as Fidler suggested, “agitate growing doubts about the policy wisdom of framing public health surveillance and response capacities as instruments of national security”. Whilst in general I am one of those who has serious reservations about the wisdom of securitization as a strategy for the public health community, I remain relatively relaxed about the BWC case. It is true that there is a need for caution, particularly over the source of funding for BW-related health-sector capacity building. That aside, the downsides for health seem likely to remain relatively limited, although we need to recognize that the upsides may be just as limited. Here I raise two issues which relate the integration of public health into the BWC process to the potential balance between risks and rewards in the securitization of health. The first is whether health may be more or less vulnerable in particular fora to the kind of distortion which some see as a damaging side-effect of securitization. The second is whether, given the progress made in the securitization of health, there is scope for public health integration into the BWC to bring meaningful additional gains in terms of the prioritization of health.

Security-oriented and health-oriented fora
One of the notable things about the securitization of health over the last decade or so is the fact that it has been bi-directional: security policy communities have become increasingly interested in the threat posed by infectious disease (both man-made and naturally occurring) whilst at the same time attempts have been made by those within health policy communities to frame certain health issues in security terms. As a result there has been a dramatic increase in the extent to which the agendas of these two communities overlap. Two of the clearest examples of the coming together of these policy communities have been seen in developments around the BWC and the IHR. The fora within which these two processes have taken place differ fundamentally in their aims, norms, procedures and (also importantly) in the types of representatives which states send along. The IHR were negotiated within the context of the World Health Organization - a setting oriented towards health as the primary goal. The BWC RevCon is very different, being a forum dominated by arms control concerns and led by security actors who have only relatively recently come to see public health capacities as having a major role to play. Public health, therefore, finds itself playing an ‘away game’.

A logical assumption may be that public health is more ‘at risk’ within security fora than within health ones. Yet this may not in fact turn out to be the case. Certainly, as has been widely recognized, the kinds of disease surveillance and response measures which are required for BW purposes will also be of benefit in relation to naturally-occurring disease outbreaks. There is a potential, then, for both communities to benefit from health’s engagement in the BWC provided that any resources committed to strengthen this surveillance and response infrastructure as a result are genuinely additional to health and do not entail the diversion of money and effort away from other health priorities. The real danger for health is that this may not always be what happens in practice. Ironically, public health may be more at risk when security considerations are brought into health-focussed fora. As one example, it has been suggested that the WHO should take on a role in investigating alleged incidence of BW use and that it should co-operate with the UN Security Council in the event of a BW incident. Yet Christian Enemark is surely right in arguing that “this could tarnish the non-partisan image upon which the Organization relies to work effectively”,¹ ultimately bringing about negative consequences for international health cooperation.

Whilst I believe there are good reasons to generally doubt the wisdom of linking public health too closely with security interests, and to doubt the wisdom of associating health-focussed bodies such as the WHO too closely with security agendas, the limited and instrumental development of public health capacity through the BWC process is not in itself a bad thing and probably does not in fact offer too much downside for health - again, providing that the resources required are genuinely additional.

Still more to gain from further securitizing health?
But if the downside is limited, what of the upside? I think there are real question-marks over whether some of the supposed benefits of securitizing health still apply. One of the key claims for securitization is that it can help to move health issues up international agendas. Yet the kinds of health activities being prioritized through the BWC process – disease surveillance and response capacities – have already moved up international agendas in recent years, even if the infrastructure in many developing countries in particular remains weak. Potential health threats such as an influenza pandemic now have a prominent place in national security plans such as the UK National Risk Register,² the US National Security Strategy,³ and this prioritization has also been reflected in the expansion of the remit of the Global Health Security Initiative to cover pandemic influenza as well as its original focus on bioterrorism. Political attention for these issues is in place, what we are lacking are the resources to build a truly comprehensive global disease surveillance net. As Fidler argues, the prospects of these additional resources emerging through the BWC process seem limited in the current financial climate. In other words, we may already have cashed-in the securitization dividend and the upside of public health’s integration into the BWC may be more limited than some had hoped.

References

1. Christian Enemark. 2010. ‘The Role of the Biological Weapons Convention in Disease Surveillance and Response. Health Policy and Planning vol.25(6): 492.
2. Cabinet Office. 2010. National Risk Register of Civil Emergencies, 2010 edition. (London: HMSO). Available at http://www.cabinetoffice.gov.uk/sites/default/files/resources/nationalriskregister-2010.pdf
3. DWhite House. National Security Strategy, May 2010. Available at http://www.whitehouse.gov/sites/default/files/rss_viewer/national_security_strategy.pdf

When discussing securitization of public health from an academic perspective it is important to recognize the fact that in case a bioweapon incident occurs, the local public health service will have to react first. This is simply the duty of this service. This part of the medical system is going to have to shoulder most of the workload, especially in the long run. This is also the case when it comes to identifying hoaxes and to supporting the local community.

It is the same local service that ideally is aware of the needs of the people. And exactly these public health officers are going to continue serving their communities when international and national experts have left the area. We all have learned that attacks like the sarin case in Japan or the anthrax letters in the USA have long- term effects on the well-being of the communities

To fulfil their duty the public health officers, especially on the local level, have to enjoy the trust and support of the local citizens. A clear understanding of the role and limitations of public health and a working knowledge about the wishes of its partners are needed. In the following I am going to set out my personal views on the role of public health on the local level in the post 9/11 environment.

Looking at public health institutions on the local level worldwide we still find that way too many are underfunded. In some places of the world they are even non-existent. At the same time the demands are growing – not only in the field of countering bioweapons. The public health effects of hunger and the relationship between poverty and health are just two of the most urgent problems. Another pressing issue is the problem of HIV/AIDS.

After 9/11 the public health sector was drawn into the public: Many new partners, not only from the security branches, suddenly had many and diverse requests. In particular, all of them wanted instant answers and reliable information. In my view too many colleagues from the local health authorities were not aware of these needs. Moreover, at first they were badly prepared to fulfill them. Before 9/11 public health had been struggling to comply with their duties without much notice from the outside. Most important: in many cases no cooperation agreements with law enforcement or disaster medicine existed. Different mentalities met: Public health services are (and should be) willing to share information and know-how as long as protection of personal data is secured. The new partners, especially in the security branch, tend to be more cautious when sharing information. Sometimes they do not share them at all.

Clear rules, especially in the field of data protection, have to be established to make cooperation possible. For example: Many patients would be willing to share personal medical information with a public health worker, but not with the police. This is true for instance in the case of a drug-addicted person or a psychiatric patient with paranoia. The public health system can only function properly when trusted by its clients. When the public health system does not ensure that clear rules are put in place and implemented it will lose this trust.

In this field of cooperation, public health authorities have to keep in mind that the funding of its institutions only for the sake of security does not work. We all have witnessed, that after 9/11 the governments in the Western hemisphere have invested heavily to support their public health systems. But they have cut funds as well, and rather quickly. Public health and law enforcement are partners in very few, though important, areas. I do think that public health cannot gain much from the “securitization” of its field.

In this intervention, I address points made by Simon Rushton and Martin Dirksen-Fischer in their contributions, identify the central question for the Seventh RevCon’s concerning the securitization of public health, and recommend specific RevCon actions on this issue.

Responses to Rushton and Dirksen-Fischer

Rushton’s and Dirksen-Fischer’s reflections on my original contribution express skepticism about linking public health to the BWC. For Rushton, developing public health capacity through the BWC is not a bad idea provided that this process contributes something additional to capacity building. However, Rushton doubts whether the BWC process delivers because we still lack “the resources to build a truly comprehensive global disease surveillance net.” Dirksen-Fischer’s skepticism—drawn from his experiences as a public health practitioner—is deeper. He argues that funding for public health based on security concerns “does not work” for public health. Dirksen-Fischer believes that securitization distorts the public health mission, thus revealing his disagreement with Rushton concerning the downside of including public health in the BWC. In short, while Rushton concludes we have “cashed-in” on benefits the linkage might have created and should expect no more upside, Dirksen-Fischer asserts that securitization has been, and will continue to be, a mistake for public health.

In analyzing the contributions securitization has created for public health, Rushton states that “as has been widely recognized, the kinds of disease surveillance and response measures which are required for BW purposes will also be of benefit in relation to naturally-occurring infectious diseases.” This statement reflects the “synergy thesis”—the idea that improvements in surveillance and response capabilities against biological weapons also benefits public health. However, these promised synergies have been more rhetorical than real. BW-focused surveillance and response efforts do not always strengthen public health capabilities to address naturally occurring infectious diseases.¹ As Dirksen-Fischer asks, how have the billions spent on BW-targeted surveillance and response helped public health address HIV/AIDS—one of humanity’s worse disease pandemics that continues to spread death and suffering worldwide?

However, Dirksen-Fischer’s position—that public health should sever the securitization link—is not credible. First, public health authorities do not determine public health’s place in the BWC agenda and remain subject to demands of the security community and its concerns about biological weapons. Second, public health officials do not want to give up the political attention the securitization path within the BWC process brings to surveillance and response concerns, even if epidemiological payoffs do not materialize.

The central question and recommendations for the Seventh RevCon

For the Seventh RevCon, the central question is: How can the BWC process contribute effectively to building broad-based public health surveillance and response capabilities on a global scale? Answering this question involves two steps, which form the basis for my recommendations. First, BWC states parties should brief the Seventh RevCon on specific public health efforts undertaken because the BWC process has targeted public health. This recommendation addresses the lack of good information on whether the BWC process’ consideration of public health has resulted in public health capacity-building actions. As Rushton pointed out, states have undertaken much activity in this realm outside the BWC, so the briefings to the Seventh RevCon should focus on those efforts directly flowing from BWC-based activities. Such briefings should provide a picture on how useful the securitization path in the BWC has been in practice and avoid crediting the BWC process for actions inspired and directed from non-BWC initiatives.

Second, based on these briefings, the Seventh RevCon should formulate an action plan for public health capacity-building that goes beyond recitation of the “synergy thesis.” BWC states parties should table such an action plan as part of efforts to strengthen cooperation under Article X. The action plan should (1) request that the BWC Secretariat, WHO Director-General, and UN Secretary-General collaborate on a report identifying specific capacity-building contributions the BWC process can make to global health security; (2) integrate the plan’s objectives with on-going capacity-building initiatives connected with global health security, especially much-needed implementation of the International Health Regulations (2005); and (3) appoint an independent group of experts to assess periodically progress on the action plan.

These recommendations seek to make the BWC-public health relationship more than “low-hanging fruit” for the Seventh RevCon and challenge the BWC process to take the securitization of public health more seriously, especially the “public health” aspect of this phenomenon.

References

1. For more on the significant problems with the “synergy thesis,” see David P. Fidler and Lawrence O. Gostin, Biosecurity in the Global Age: Biological Weapons, Public Health, and the Rule of Law (Stanford University Press, 2008), pp. 147-184.

Two divides have come through particularly strongly in this discussion of the place of public health in bioweapons control. Both are obvious, but are nevertheless worth noting.

The first is a global-local divide: that what happens at the global level has implications for the local level. Any agreements reached in fora such as the BWC RevCon - on improving public health surveillance capacity, for example - ultimately have to be implemented by those working ‘on the ground’ in public health institutions. As Dirksen-Fischer pointed out, the extra demands which result from securitization (and which do not always in practice bring an equivalent increase in capacity and resources) are not always welcomed by those at the sharp end. Fidler suggests a need for better evidence about what precisely has happened to public health capacity as a result of the BWC process and makes the practical and sensible suggestion that states-parties should brief the Seventh RevCon on what they have done.

The second divide is between what can reasonably be expected of public health systems in the developed and the developing worlds. States differ markedly in the strength of their existing public health infrastructure. Dirksen-Fischer’s intervention describes the pressure which even a wealthy country’s public health authorities can come under as a result of the increased interest of security communities in public health, and he rightly points out that “in many places in the world [public health institutions] are even non-existent.” Where they do not exist this is not generally the result of a lack of prioritisation of health, but rather a lack of the resources necessary to put them in place.

There are currently 163 states-parties to the BWC. All would be affected by any capacity-building initiatives which the BWC process adopts. The experience of IHR implementation is perhaps a warning of the possible difficulties which might be encountered in any attempt to promote public health capacity-building via the BWC process. The core capacity requirements which the IHR set out for states have in many instances been found to be too onerous and the level of support which has been provided by the international community has been inadequate. A number of states, therefore, have so far been unable to meet these requirements.

Fidler’s proposal for the formulation of an action plan is again a good one, but as always with such plans the devil would be in the detail. What would be required of states? Perhaps even more importantly, how will any capacity-building be funded and implemented? As I suggested in my first intervention, there is a need to guard against health sector resources being diverted to address security priorities. Any new capacity required as the result of such a plan should be funded from security budgets, not health budgets. And the reality is that developed Western states will need to come up with many of the resources necessary to implement any such plan in practice.

This is especially the case because, as Fidler noted in his first contribution to this discussion, BW is well down the list of health priorities in many countries, and especially countries in the developing world who suffer from the highest burden of disease. There are feelings in some quarters that the IHR capacity requirements have imposed obligations on developing states which are essentially the product of Western security interests. That feeling would surely be even stronger in any situation in which capacity building was required under the BWC process.

In short, the steps proposed by Fidler are worthwhile and valuable activities which would indeed represent significant progress at the Seventh RevCon. The problem would clearly be achieving subsequent agreement on whatever plan of action the BWC Secretariat, the UN Secretary-General and the WHO Director-General were to propose. Here the two divides – between global negotiations and local implementation, and between the relative capacities and sometimes divergent interests of the developed and developing worlds – would again rear their heads.

Since my last posting there were two events that I would like to share with the readers of this discussion. In an interview with the Washington Post (published online on 16 June 2011) Thomas R. Frieden, the head of the CDC, mentioned that the public health workforce in the USA has lost nearly 45,000 experts in the last two years at the local and state level due to funding cuts because of financial problems. The CDC lost another 1,000 men and women. The budget of the CDC was cut by 11 per cent by the federal government. In the interview, Frieden points out the problems that the CDC has due to these reductions in funding. May I ask not to forget that funding is cut in the field of public health all over the world, not just in the USA?

The second event: Starting a couple of weeks ago – with a focus in Hamburg and Northern Germany in general – we had a shiga toxin producing Escherichia coli O104:H4 outbreak. More than 40 people died, thousands fell ill.

There was not the slightest hint that this EHEC outbreak was an act of bioterrorism. The German government and the European authorities assured the public on this point a couple of times. The public health service, together with the clinicians and the public in general, managed this outbreak which hopefully will come to an end in a couple of days. The German public health system came under considerable stress.

So what do these two events have to do with each other and especially with the Bioweapons Convention? It simply makes clear, from my point of view, that public health has to be strengthened, not weakened, to solve the daily problems in this field, not to speak about bioweapons attacks which remain a possibility.

I personally think that two highly industrialized and still very rich countries like the USA and Germany should set an example by not further cutting funds for public health. I support Fidler’s recommendation that the member states of the BWC should report on their efforts over past years to support public health. Fidler also asks for a (much needed) action plan to support the BWC in general. Rushton (together with other leading experts in the field) reminds us of the problems that many states have with implementing the IHR: These countries urgently need our support and solidarity for the years ahead.