52 attendees from a range of sectors
Following the Ebola outbreak of 2014-16, global health security experts from around the world met at BMA House in London to:
52 attendees from a range of sectors
26 organisations represented
5 expert panellists in global health security
“To be successful in global health security, we need to take a multidisciplinary, multisectoral approach and that's really challenging because people are stuck in a vertical disease programme like HIV/AIDS or tuberculosis. It's important we get them to the table and look at how they can work together as a team to take that whole community approach.”
Gavin Macgregor Skinner, Global Health Security, ABT Associates
High-level panels have been held by the United Nations, ambassadors of health security have been appointed, new initiatives have been created such as the US-led Global Health Security Agenda (GHSA) and the Joint External Evaluation (JEE) Alliance, the World Health Organization (WHO) is being reformed to assume a more operational role in outbreak response, and the G20 is again discussing health. Yet while there remains a lot of political interest in the topic, the concept of global health security and what it means remains hotly contested. The problem is that not many people know precisely what it means. At least, not yet.
Professor Neil Squires, Director of Global Health, Public Health England and Mitali Wroczynski, Head of Strategic Partnerships for Global Health and Global Health Security, BMJ, co-chaired a meeting attended by leading academics, representatives from non-governmental organisations (NGOs), industry partners and government officials at BMA House, London. Hosted in partnership with Chatham House and Abt Associates, the meeting reflected on the global health crises and explored avenues in which the UK can contribute to strengthening global health security now and into the future.
The meeting commenced with a number of short presentations from delegates on themes covering:
Participants were tasked with discussing a range of issues that extended from identifying the priorities, lessons learned and synergies within global health security, to reflecting on stakeholder engagement and next steps. Some argued for a narrowing of the concept, advocating that global health security should apply exclusively to the control and elimination of infectious diseases and other fast-moving, acute health challenges.
This position is consistent with the WHO’s stated definition of global public health security; and advocates for limiting the concept highlighted that if every health concern becomes a security issue, then nothing is a security issue. Although there is no guarantee given the turbulent nature of global health funding at the moment, adopting such a narrow definition could result in more strategic investment in disease surveillance and outbreak response capacity, thus aligning more with global agendas such as the JEE Alliance and international frameworks such as the revised International Health Regulations. Even if a narrow definition was adopted though, such targeted investment remains to be seen.
Yet other participants suggested that security (especially biosafety and biosecurity e.g. secure storage and transport of potentially hazardous samples, safe/secure working practices and promotion of a culture of responsibility) should be considered as an intrinsic element in “health security” and not something that is an optional add-on. It is worth remembering in this context that the G7 Global Partnership Security Programme has had strong links to the GHSA from the latter's inception and shares many common aims.
For others, the securitisation of health serves more as a strategic tool to either raise the profile of a particular health problem or extract resources from governments to bolster public health programmes or initiatives. David Heymann argued that global health security should be broadened to include both collective and individual (including health worker security) security, incorporating pressing issues such as access to healthcare and equitable treatment.
The Director of Chatham House’s Global Health Security programme remarked that global health security was "very much like a chameleon" as its meaning varied considerably depending on the eye of the beholder.
Such an approach has its merits as well as its problems though. For, on the one hand, while expanding the issues that fall under ‘health security’ may help raise their profile (with the potential added benefit of an associated rise in funding to address the problem), at the same time it may add to yet further ideational confusion around what is, and what is not, a health security issue while diversifying investments so that only incremental change is possible.
Within this entire discussion though, it is important to appreciate that the majority of the academic community has been staunchly opposed to the conflation of health and security, arguing that it represents a dangerous development. In this, critiques have broadly followed one of three trajectories. The first argues that the concept of health security reflects neo-colonial Western, high-income countries’ interests; that because this is effectively about ‘protecting the West from the rest’ it is morally and/or ethically bankrupt. The second common criticism pertains to the distorting effect that framing health issues as security threats can have on public health, leading to emerging infectious diseases being given disproportionately higher resource even though they may result in less human morbidity and mortality. The third line of critique relates to the actors it attracts, such as the military services which, it is often assumed, will lead to a diminishing of human rights, and/or humanitarian principles. Though the positive contribution of the UK military during the Ebola outbreak is widely acknowledged, it must also be recognised that this was in part due to the strong history of post-reconstruction work and relationships in West Africa.
Prior to the Ebola outbreak, it is also worth remembering that there were several governments that publicly criticised initiatives like (and important organizations like the WHO) for merging health and security. Of those, Brazil has been the most consistent; and Brazil is amongst a handful of countries (alongside Russia, India and China) that have reportedly declined to participate in the JEE Alliance external evaluations which seek to verify government’s compliance with the International Health Regulations on the basis it infringes their sovereignty. As others have noted though, this now seems to be a consistent theme and behaviour. Importantly, however, it remains unclear whether opposition to ‘global health security’ will once again grow.
After much debate on the definitions of health security at the BMJ meeting, there was a general consensus that we must now move towards mapping and accelerating the health security activities already being conducted and addressing identified gaps in countries’ preparedness in a coordinated manner which is sustainable and maximises the resources available. Some participants argued strongly that existing tools such as the Sendai Framework for Disaster Reduction" (UNISDR), approved by the UN in 2015, provides the blueprint for this.
BMJ and Chatham House concur on the need for a paradigm shift which focuses attention on prevention and preparedness at a local or regional level, as opposed to broad statements of intent issued in global forums. Health systems need to be resilient, and have the capacity and capability to not only respond to a crisis but also maintain their core functions. For this, real action is needed; and the appropriate time for helping countries create resilient health systems is outside the context of an emergency or crisis. Said another way, now is the best time to make progress in helping countries strengthen their health systems so that they can respond effectively to global health security threats whenever they arise.
Serving as both a forum for future discussions as well as a dissemination mechanism for publishing leading edge, evidence-informed research, conceivably one of the key contributions that BMJ could make in the field is to help in defining the parameters of the concept and sharing implementation best practices to support acceleration. In this space, arguably one of the biggest contributions the journal could make is to help move the practitioners, policy-makers, and scholars closer to a consensus on what ‘health security’ means.
For unless global health security is to serve as a new catch-all, there is a need for delineating the areas of global health security practice. It is an ambitious agenda, but one that is desperately needed to save lives in the future.
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