Securitizing disease undermines effective responses.

Health as an issue of national security has been well-established over the last three decades. Jeremy Youde provides a useful discussion of both advantages and disadvantages of health securitization, identifying that while health securitization can garner attention for an issue (evidenced in the AIDS epidemic), and resources to address it that might be activated on a global scale, it simultaneously can feed into an us-versus-them mode of thinking (Youde 2022). Youde identifies the negative elements of increased surveillance, and the reproduction of paternalistic relation- ships between global North and South. Stefan Elbe (2006) looked closely at the global AIDS pandemic through the lens of securitization theory, as revelatory of the normative dilemma at the heart of securitization of health (Elbe 2006). This normative dilemma is characteristic of securitization in general: while securitizing something may raise awareness and, crucially, may direct state funds towards a targeted issue, it simultaneously invites military responses that often involve the suspension of civil rights and liberties, and it raises a threat-defence logic (2006).

The racialised dimensions of AIDS are well-established in health literature with racial and ethnic disparities evident in infection rates and outcomes (Stone 2012; Bhana 2006; Elbe 2006). While there are racialised tendencies to apportion ‘blame’ and to control movement, minoritized people are more likely to die from AIDS: this is not a discretionary behaviour of the virus, rather it reflects extant health inequalities that can be observed both globally and more locally in individual states. As Youde (2008) warns in his discussion of the potential securitization of Avian flu H5N1, securitization of health involved ‘us-versus-them’ thinking, and evoked efforts to guarantee flu vaccines (Youde 2008). The effort to prepare for a pandemic in case it happened in America before human-to-human transmission was known, was the priority and arguably displaced AIDS and other real-but-distant ongoing crises such as Malaria from the global health agenda. As Sophie Harman (Harman 2021) succinctly argues:

The health issues that threaten millions of lives in low- and middle-income countries but pose very little risk to high-income countries are rarely considered to be matters of global health security and so are not prioritised, while simultaneously people living in low- and middle-income countries are then framed as the threat to the West, as vectors of disease, and are thus subject to discrimination which is often highly gendered and racialized. Global health security thus both exacerbates and reproduces inequality by creating a hierarchy of health issues (Harman 2021: 607).

Infectious disease lends itself to securitization, as Metelmann et al. argue (Metelmann et al. 2022). Of course, the securitization of Covid-19 is the quintessential example of securitization justifying the suspension of civil liberties on an extreme scale, albeit one that varied by country, in the context of a health emergency. Metelmann et al. explore the implications for non-communicable disease, and specifically disease treated by surgery—but this could also be applied to other public health issues. These authors find that surgery specifically has low securitizing potential and this is in part due to its high infrastructural demands: surgery requires public investment. The authors note that there is a bias towards prioritising infectious diseases because the means of addressing them are relatively simple and do not always necessitate high-level medical expertise (such as containment, and vaccine programmes). Surgical disease on the other hand can- not be contained or addressed in the same way: for example, appendicitis is not infectious and cannot be prevented with a vaccine programme. The authors demonstrate this argument with the evidence that the ‘Public Health Emergency of International Concern’ (PHEIC) declarations of the last decade all referenced an infectious disease despite the fact that public health, and therefore public health security, is of course much broader. What is perhaps as—if not more—significant than resources, is that non-communicable disease such as appendicitis does not lend itself to an us-versus-them logic and therefore does not evoke the logic of security.

In terms of global health security, the WHO has taken an increasingly significant role on deciding the security exception (Hanrieder and Kreuder-Sonnen 2014). As Hanreider and Kreuder-Sonnen discuss, this top-down institution with no direct enforcement capability can usefully draw on security language to activate the capacity of states to enforce containment of infectious disease. While the WHO might be the securitising actor in this context, the audience that co-constitutes the threat is the state, and states retain the responsibility to make and implement security policies. This can operate as a means of protecting the most vulnerable. Nevertheless, there are varied and intersectional forms of vulnerability, exacerbated by massive inequality in the world. Recent work on the Covid-19 pandemic has begun to draw attention to some of these significant vulnerabilities attached to inequality and power. Where the spread of the infectious virus was securitised, it raised significant insecurities for people at risk of suffering domestic abuse (Kourti et al. 2021). Risks linked to low socioeconomic status such as unstable income and financial uncertainty that are linked to mental health and heightened stress were exacerbated by lockdowns (Patel et al. 2020). A special issue of American Behavioural Scientist explored the cross-cutting and intersectional inequalities exacerbated by the pandemic, revealing the interplay of race and ethnicity and socio-spatial inequalities (Kuk et al. 2021), and the gendered disparities produced by home-schooling and gendered domestic structures (Bari- ola and Collins, 2021). Additionally digital inequalities, which might be socioeconomic but also intersect with other variables such as age, education, and disability, were linked to bodily stress and anxiety during the Covid-19 pandemic (Robinson et al. 2020, 2021). The relevance here is not to make an argument about the efficacy of lockdown or to critically assess responses to the Covid-19 pandemic, but to demonstrate that there are particular public health-based insecurities and vulnerabilities that can be directly produced by an act of health securitization. Securitizing acts in one area produce insecurity and vulnerability in another.