Focus on biosecurity as a panacea is a Neoliberalist mask that worsens diseases and inequality for the vulnerable.

The COVID-19 outbreak has highlighted the continuing menace to humanity of global health issues that had been suppressed and considered under control, at least in the Global North. The massive warfare activities in Ukraine in the third year of the pandemic have reawakened the sense of threat particularly in Europe. Both the pandemic and the war, as well as the escalating climate crisis, have made global insecurity more tangible. The existing and likely crises caused by these unfortunate occurrences – mass displacement, increasing prices for products of basic needs such as food and energy, and the overall severe impact on global economy—will burden people in low-income countries most but not at all exclusively [1]. Especially the fatal effects on future generations [2] understandably reinforce the desire for a safer world. Enhanced security is needed in times of growing uncertainty, threatened ancestral rights and dwindling opportunities for a large part of mankind. The current global order has therefore been aptly described as a world risk society [3]. Even if this need for security is comprehensible, the nature of the security discourse in global health and beyond raises fundamental questions and concerns. Instead of pursuing common objectives, such as social stability, global public goods, equity or social justice, and recognizing shared responsibilities by governments across national boundaries, security policies predominantly envisage biomedical threats such as infectious diseases, more or less openly admitting that the focus is on the autonomy of nation states and safeguarding the existing status quo in international relations, however unfair they may be [4]. The utopian exuberance that led to the founding of the WHO and other United Nations (UN) organizations is thus giving way to a pragmatic, predominantly biomedical realism that undermines rather than promotes people’s rights and legal entitlements, as enshrined in the Universal Declaration of Human Rights and in the WHO constitution [5]. The SARS-CoV-2 pandemic has highlighted the extent to which global and public health has become dominated by biomedical approaches. Politicians, policymakers and the media provided virologists and epidemiologists a paramount role in dealing with the pandemic. For a considerable time, they provided the main evidence base for partly far-reaching measures and restrictions. The strong, near-exclusive focus on biomedical sciences and their assessment of the pandemic situation led to the initial ignorance of the non-medical, social determination of health. In Germany, for example, it took the dominant COVID-19 experts and political decisionmakers 14 months to even notice the pronounced socioeconomic differences in the burden of the coronavirus infection [6]. The ongoing debate about the COVID-19 pandemic and its interrelation with health security does not sufficiently put the spotlight on the structural causes of global health crises. Despite overwhelming evidence of the social determination of health, political leaders, the media and an influential part of global health actors have focused first and foremost on biomedical approaches [7], while often underestimating or even ignoring the close relationship between socioeconomic status, living conditions and unhealthy lifestyles on the one hand, and both the burden of non-communicable diseases and the severity and lethality of COVID-19 infections on the other [8, 9]. A narrative, iterative review of the available literature on health security indicates an increasing biomedicalization of public health that has contributed significantly to making the linkage between health and security the priority discourse in global health and its governance. Security aspects and considerations have gained both acceptance and importance in the last decades. The quest for security is understandable in an increasingly inequitable, unstable and disjointed world, particularly vis-à-vis the militarization of conflicts and international relations. But a closer look at the concept of health security makes things appear more complicated. It often remains unclear what is meant by this form of security, who defines it and who is being targeted by security policies as well as how health security is to be generated [10]. Health security remains centered on the security of nation states and defence against international threats, rather than prioritizing people’s health and its determination [11]. Policymakers in high-income countries tend to emphasise protection of their populations particularly against external threats, for example bioterrorism, zoonoses and pandemics, whereas many—but not all—global health professionals understand the term in a broader context of social health protection, population health and its determination [12]. Over the last two decades, global health security has often become virtually and almost interchangeably synonymous with global health [13]. However, this perspective rather exhibits a conceptual narrowing than epistemic clarity. Global health security is actually but one area of the global health domain, as it primarily addresses cross-border health threats but not the whole span of global health policy [14, 15]. Meanwhile, a universal definition of global health security is still lacking, despite the abundance of available literature on human and (global) health security. The recent attempt of the WHO, as the United Nations (UN) agency specialised on health, to define global health security falls short as it focuses predominantly on the international spread of acute infectious threats [16]. The fact that the use of the term “health security” by different actors is as widespread as it is inconsistent is by no means attributable to the difficulty of achieving conceptual clarification, but rather to the widely divergent perceptions, interests, priorities, politics, and power relations that exist in the broader field of global health [17]. Despite its widespread use, the World Health Assembly has not yet agreed on a resolution on the concept of ‘health security’, indicating that its scope is contested among member states [18]. Health security in international foreign policy Already before the COVID-19 outbreak, global health was high on the international political agenda and played an important role at summit meetings of international fora of high-income and emerging countries such as the “Group of 7” (G7), and the “Group of 20” (G20) [19]. However, the prevailing global health security approach tends to be insufficient for adequately catering to the complexity of challenges. There is a need to harmonize the contemporary security debate with other fundamental health-policy challenges from an equity perspective [20, 21]. Current global health programs often fail to fulfill the claim to universalism implicitly associated with the term “global” and tend to neglect the requirements of a comprehensive transdisciplinary and interdisciplinary understanding of health security policies. There is still a large discrepancy between the current state of knowledge on improving health security, equity and actual global health politics and practices [22]. This trend is partly attributable to the unexpected resurgence of epidemic risks that were considered defeated or at least controllable in high-income countries in recent years. Since the last two decades, a rapid (re)-emergence of pathogenic infectious diseases has been seen in several regions of the world, including, but not restricted to, diseases such as SARS, avian influenza, Ebola, Zika, and most recently, COVID-19. These outbreaks have each led to the application of control measures around the world and strongly influenced the global health debate in which securitization has become a prevalent and common theme among global health scholars and practitioners [23]. At the same time, other health threats such as tuberculosis, malaria, or chronic conditions like cardiovascular diseases and diabetes mellitus persisted. However, neither poverty-related infections nor the growing prevalence of non-communicable diseases have ever received the attention they deserve due to the continuous upward trend, particularly in countries in transition [24]. Notwithstanding this alarming global burden of disease trend both in the Global North and South[25], it is not the major killers, but the rapid succession of transnational ‘health crises’ caused by viral infections that repeatedly provoke a state of alert and make the headlines. However, public interest in the general health related challenges of other countries and continents is usually short-lived and transient. In low-income countries the situation is fundamentally different. Certain health hazards persist and the risk of ‘endemic’ diseases and their underlying ‘syndemics’ is part of everyday life [26]. In the course of epidemiological transition, the disease spectrum is increasingly expanding or even shifting from infectious to non-communicable, chronic diseases. During the last decades, societies in the Global South and elsewhere have been facing a double burden of disease caused by bacterial, viral or other pathogens on the one hand, and health problems commonly referred to as non-communicable diseases (NCD’s) on the other [27]. The simultaneous coexistence of undernourishment, malnutrition or dietary overweight exacerbates the situation [28]. Securitization of global health Global health has become an important area of foreign and security policy and hence of international diplomacy [29]. In fact, the UN Security Council has addressed health beyond the issue of epidemics and pandemics and taken the role of a forum to debate and negotiate global health issues; this reflects primarily the political interests of the permanent five, particularly the USA [30]. Health security often shapes the global health debate more than other health issues. Security is frequently encountered as a contextual framework in political health and foreign policy documents, and the securitization of health has for some time now been considered a key feature in global health governance [31]. Security practices and medical knowledge share a common evolutionary history; to consider and analyse them as independent of each other would be to ignore the historical formation of nation states and also the colonial roots of global health [32]. Security is one of several global health “frames” that are by no means exclusive, but have been driven in recent decades by a deep core of neoliberal values [33]. This implies that in contemporary global health governance there is an overemphasis on agency, while deeper structures, including its embedded ideas and configurations of powers, are neglected [31]. As such, neoliberalism has become the globally “hegemonic paradigm” during the frst two decades of the twenty-first century [34]. Covid-19 and viral neoliberalism must be understood as co-pathogeneses whereby the corona-virus pandemic has disclosed and reinforced global health insecurities due in large part to market-driven policies and neoliberal practices; the combination of societal inequalities, weakened response capacity by marketized health systems and biomedicine-oriented global health governance have created vectors of vulnerability [35]. The health security paradigm has its roots in concepts of risk mitigation and adaptation [3]. The Ebola outbreak in Western Africa in 2014–2015 has been important for the paradigm shift in global health policy. Since then, experts and politicians have been discussing the establishment of heath emergency funds, the formation of rapid reaction medical forces (‘white helmets’), as well as the creation of robust care structures and resilient health systems [36]. The 2015 Johannesburg Summit on China Africa Cooperation identified Public Health as one of the cornerstones for foreign policy action in the China Africa cooperation [37]. During their 2017 Berlin meeting the health ministers of the G20 countries simulated the necessary measures for combating future pandemics [38]. However, the prevailing reasoning does not aim to address the structural causes of potential threats [39], but serves as “a form of immunization to have societies and systems become more resilient in dealing with future risks” [40]. In this light, one should also analyse the process for establishing an international pandemic treaty, under WHO auspices, as a global normative framework for the preparedness and response to future pandemics [41]. This pandemic agreement, which at the time of writing is under negotiation by WHO member states, deserves critical scrutiny as its focus ought to be on people’s health, not merely national security. Creating genuine global health solidarity focused on human security requires a new pandemic agreement that mandates the sharing of technologies, scientific capacities and finance in future pandemics [42]. Wenham and colleagues argue that the key tension of the pandemic treaty is rooted in globalist ideals of what the perfect pandemic governance should look like, yet “that it seems to have little regard for the realities of the statist, securitized landscape that exists for responding to pandemic threats… Even something as big as a major global pandemic is not sufficient to get governments to think beyond national interests” [43].