"US Foreign Policy Regarding the Spread of Diseases in Nigeria"

DEBATE Open Access

Coincident polio and Ebola crises expose similar fault lines in the current global health regime Philippe Calain* and Caroline Abu Sa’Da

Abstract

Background: In 2014, the World Health Organization (WHO) declared two "public health emergencies of international concern", in response to the worldwide polio situation and the Ebola epidemic in West Africa respectively. Both emergencies can be seen as testing moments, challenging the current model of epidemic governance, where two worldviews co-exist: global health security and humanitarian biomedicine.

Discussion: The resurgence of polio and the spread of Ebola in 2014 have not only exposed the weaknesses of national health systems, but also the shortcomings of the current global health regime in dealing with transnational epidemic threats. These shortcomings are of three sorts. Firstly, the global health regime is fragmented and dominated by the domestic security priorities of industrialised nations. Secondly, the WHO has been constrained by constitutional country allegiances, crippling reforms and the limited impact of the (2005) International Health Regulations (IHR) framework. Thirdly, the securitization of infectious diseases and the militarization of humanitarian aid undermine the establishment of credible public health surveillance networks and the capacity to control epidemic threats.

Summary: The securitization of communicable diseases has so far led foreign aid policies to sideline health systems. It has also been the source of ongoing misperceptions over the aims of global health initiatives. With its strict allegiance to Member States, the WHO mandate is problematic, particularly when it comes to controlling epidemic diseases. In this context, humanitarian medical organizations are expected to palliate the absence of public health services in the most destitute areas, particularly in conflict zones. The militarization of humanitarian aid itself threatens this fragile and imperfect equilibrium. None of the reforms announced by the WHO in the wake of the 68th World Health Assembly address these fundamental issues.

Keywords: Global health, World Health Organization, Polio eradication, Ebola, Security, Militarization, Epidemic response, Humanitarian action, Disasters, International Health Regulations

Background Drawing from international relations theory, the con- cepts of international regime, hegemonic stability and collective security have been used by scholars to analyze trends in the governance of global health. Focusing on epidemic diseases, Hoffman [1] defines the "global health security regime" as "the implicit or explicit principles, norms, rules and decision-making procedures by which international actors (including both states and civil society organizations) aim to protect their constituencies from the

transmission of diseases from one area to another". Rather than a mere description of the roles and responsibilities of global health actors, this approach provides a better under- standing of the complexity of epidemic governance. Fur- thermore, Lakoff [2] opposes as distinct regimes "global health security" and "humanitarian biomedicine" for their different visions of global health priorities. In our view, both global health security and humanitarian biomedicine inevitably co-exist in a complex political landscape defining the current "global health regime". Significantly, this regime has been put to the test in two coincident epidemic events of international dimensions, caused respectively by poliovirus and ebolavirus. Twice in 2014 (on May 5th

and August 8th respectively) Dr. Margaret Chan, Director

* Correspondence: [email protected] Research Unit on Humanitarian Stakes and Practices (UREPH), Médecins Sans Frontières, Rue de Lausanne 78, Geneva 1211, Switzerland

© 2015 Calain and Abu Sa’Da. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Calain and Abu Sa’Da Conflict and Health (2015) 9:29 DOI 10.1186/s13031-015-0058-1

General of the World Health Organization (WHO), de- clared a public health emergency of international concern after consultation with an Emergency Committee of ex- perts convened under the provisions of the revised (2005) International Health Regulations (IHR) [3]. Made in re- sponse to increasing alarms over the international spread of wild-type poliovirus, the first declaration was the latest sign that the success of polio eradication was still uncer- tain. The second announcement was a belated recognition that the Ebola epidemic in West Africa was unprece- dented in magnitude and international spread. According to Hoffman [1], the current global health re-

gime has so far been characterised by expectations of inter- national cooperation under the "hegemony" of the World Health Organization. It is being challenged by the limita- tions of the revised IHR (2005), the proliferation of global health security organizations, new instruments of foreign policy and new threats to health security. The IHR (2005) stand out as innovative among other health treaties. They oblige State Parties to notify defined public health threats and to limit unnecessary public health measures [4]. Yet, the temporary or standing recommendations issued by the WHO are not binding for State Parties, making the IHR (2005) weak instruments for outbreak response. The mistrust of populations when public health actions

are disconnected from local perspectives has been seen in recent circumstances, for example, the ongoing resistance to polio vaccination in Pakistan and the hostility of some communities towards measures to control Ebola in West Africa. Elsewhere, coincident political violence and civil wars are operational obstacles to polio eradication and other public health initiatives, which appear in a new geopolitical context, where public health is no longer seen as politically neutral. This is the case, for example, of ongoing conflicts in the Middle East. The current global health regime is poorly fit to meet such challenges, for at least three reasons, which we will further examine: (i) the encroachment of security policies on communicable dis- eases in general, and public health surveillance in particu- lar, (ii) the constraining mandates of United Nations (UN) institutions, and (iii) the interference of security agendas with humanitarian action.

Discussion Smallpox and polio eradication: different political epochs The Global Polio Eradication Initiative launched in 1988 has been a remarkable endeavour prompted by the pre- cedent of smallpox eradication. A public-private partner- ship endowed with considerable funding from private philanthropy, the initiative followed expected tracks until the early 2000s. This initial success led to the elimination of serotype 2 poliovirus in 1999, to the possible elimination of serotype 3 since November 2012 [5], and to wild-type sero- type 1 remaining endemic in only three countries (Pakistan,

Afghanistan and Nigeria) since 2012. Unfortunately, vaccin- ation campaigns continue to be rejected by some commu- nities and their traditional leaders in specific regions of overt or latent unrest. In northern Nigeria for example, religious leaders and authorities concerned about the safety of vaccines [6] and by the precedent of the Trovan drug trial [7] boycotted polio immunization in 2003–2004, resulting in the spread of polio to 20 countries [8]. In 2013, wild poliovirus spread from Nigeria to Cameroon and Somalia, while strains from Pakistan reached Iraq, Syria, Israel and Afghanistan [9]. In 2015, the propagation of polio seems to be halted in Iraq and Syria, but the situation in Pakistan and Afghanistan remains a major public health concern [10]. Non-binding temporary recommendations issued under

the IHR (2005) are unlikely to solve the fundamental prob- lems of "the last mile" of the Global Polio Eradication Ini- tiative, which are not essentially technical, programmatic or even financial. More fundamentally, threats to the success of the Initiative are rooted in socio-cultural and political is- sues undermining confidence in vaccination programs [11]. When considering the final stages of the smallpox eradica- tion campaign, it is barely surprising that social and cultural clashes could compromise the completion of a worldwide eradication campaign. In the 1970s, resistance to vac- cination teams in India and Bangladesh was witnessed by Euro-American epidemiologists, who ultimately resorted to coercing villagers and intimidating local health care staff to achieve universal coverage [12]. What is new nowadays is the fact that polio remains endemic in zones of civil con- flicts, where health care services are seen as symbols of for- eign agendas [13]. Ongoing political violence exposes teams of polio vaccinators to being deliberately targeted by local insurgents, notably in northwestern Pakistan [14]. Ac- cordingly, WHO country plans for Pakistan, Afghanistan and Nigeria have been adjusted to include more compre- hensive public health strategies, security components and new communication tactics [15]. Ultimately, misinforma- tion by obscurantist leaders or intimidation by extremist militants are only partial explanations for the local rejec- tion of polio vaccination campaigns [16]. A more fun- damental problem is that the global health regime is currently defined by security policies, which compromise the credibility of important public health initiatives of inter- national dimensions.

Securitization of infectious diseases As a result of a prevailing focus on domestic security among industrialized countries, and in particular since the events in the USA on 9/11/2001, there has been a significant impact on the way global public health ini- tiatives have been conceived. Security interests in health became prominent in the

1990s with the recognition that communicable diseases

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(HIV/AIDS in particular) have far-reaching impact on trade and foreign affairs, beyond the strict realm of public health. In 2000, the UN Security Council passed Resolution 1308, concerned with the impact of HIV/AIDS on peace- keeping operations in Africa [17]. Following new concerns over bioterrorism, epidemic preparedness and response also became “securitized”, i.e. framed in terms of do- mestic and international security [18]. When applied to public health, the word “security” therefore carries a fun- damental ambiguity about the exact values at stake [19]. Health security can either be understood in terms of pro- tection of health, protection of trade and economy or as a matter of non-proliferation of biological weapons and counter-terrorism. This ambiguity has far reaching con- sequences, especially in the case of global public health surveillance.

Box 1: glossary

Global public health surveillance is an essential activity promoted under the IHR (2005) agenda [23], as well as one of the pillars of the Global Polio Eradication Initiative. After 2001, the security community became increasingly associ- ated with the development of global public health sur- veillance, recognizing that early outbreak detection could

identify or mitigate both natural and deliberate epidemic threats. From the beginning of the revision process of the IHR, this "dual use" argument has been a source of con- troversy. Whether the scope of the IHR (2005) includes the investigation of man-made outbreaks and conse- quently non-proliferation issues, is still open to inter- pretation. In practice the securitization of global public health surveillance is now pervasive and can be illustrated in a number of programmes deployed under private, na- tional, international or supra-national initiatives (Table 1 and Additional file 1). Far from protecting global pub- lic health from securitization, the WHO Secretariat – through its partnerships and policies – has implicitly added support to the view that public health surveil- lance is primarily an instrument of national security instead of a foundation for outbreak prevention and control [24]. For example, Article VII 39 in the final document of the 7th review conference of the Biological Weapons Conven- tion (BWC) makes it clear that the IHR (2005) are instru- mental to building surveillance and detection capacities pertaining to the BWC [25]. In this example, where the WHO is expected to provide the technical capacity to in- vestigate suspicious outbreaks, securitization is counter- productive to public health goals [26]. The blurring of lines between security, disarmament and public health surveil- lance also appears in new surveillance networks sponsored by non-proliferation lobbies, in dual use technologies or in multilateral alliances (Table 1). Securitization underpins a subtle change of vocabulary, from the IHR (2005) "public health surveillance" [23] to "biosurveillance" [20]. The latter terminology not only reflects the increasing reliance on in- formal “event-based surveillance” [22] systems for outbreak detection, but also a shift from public health to domestic security concerns [21], [27]. For example, in 2004, the US National Biosurveillance Integration System was assigned to the Department of Homeland Security [28], while in 2008 the Biosurveillance Coordination Unit was estab- lished under the US CDC’s Coordination Office for Terrorism Preparedness and Emergency Response (COT- PER) [29]. The proliferation of national and global biosur- veillance initiatives has created a new industry that brings together public health institutions, academia, private se- curity companies and the intelligence community. Coun- ter to the argument that the goals of public health and national security converge over matters of epidemic con- trol, security agendas actually prevail over public health achievements in the new health security doctrine. The fake vaccination campaign organised by the US Central Intelligence Agency (CIA) to help track Osama bin Laden showed how domestic security priorities can compromise trust in public health initiatives. In May 2011, a Pakistani doctor hired by the CIA conducted a hepatitis B vaccin- ation campaign and allegedly managed to collect DNA samples from vaccinated children to confirm the presence

Biological Weapons Convention – a multilateral disarmament treaty prohibiting the development, production or stockpiling of bacteriological and toxin weapons.

Biosurveillance – " …the process of active data-gathering with appropriate analysis and interpretation of biosphere data that might relate to disease activity and threats to human or animal health – whether infectious, toxic, metabolic, or otherwise, and regardless of intentional or natural origin – in order to achieve early warning of health threats, early detection of health events, and overall situational awareness of disease activity" [20]. In contrast to public health surveillance, one explicit purpose of biosurveillance is to contribute to domestic security and measures to counter terrorist threats [21].

Dual use – the use of programmes or technologies for both civilian and military purposes.

Event-based surveillance – "…the organised collection, monitoring, assessment and interpretation of mainly unstructured ad hoc information regarding health events or risks, which may represent an acute risk to human health" [22].

International Health Regulations (2005) – A binding set of international regulations that requires States Parties to establish a credible national surveillance and response capacity and to notify a potentially wide range of events to the WHO on the basis of defined criteria indicating that the event may constitute a public health emergency of international concern [23].

Public health surveillance – "The systematic ongoing collection, collation and analysis of data for public health purposes and the timely dissemination of public health information for assessment and public health response as necessary" [23].

Securitization – framing the theory and the practice of a discipline (e.g. public health) as a matter of national security.

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of the Bin Laden family in their compound in the town of Abbottabad. The plot was clearly condemned by prom- inent international experts as damaging the trust in the polio eradication campaign and compromising its final success [30, 31].

The paradox of UN mandates in civil conflict zones The case of Syria is illustrative of the limitations imposed by UN mandates on the capacity of the WHO to ensure adequate public health responses in areas of civil conflicts [32]. UN agencies and the WHO in particular have been perceived taking sides with the Assad regime and disre- garding the health needs of part of the Syrian population [33]. Polio vaccination activities have been very much at stake in this controversy. The Syrian Republic had not seen a case of polio since 1999. While polio probably reap- peared as early as May 2013 in Deir al-Zour Province [34], an outbreak of acute flaccid paralysis was only confirmed as polio by Syrian authorities in October 2013. A contro- versy arose when the Syrian Government and the WHO country office were accused of delaying the confirmation of cases in areas sympathetic to the opposition [35, 36]. The outbreak seems to have been curbed in 2015, al- though the reliability of surveillance data is still disputed [34, 37]. Members of the new Islamic State insurgency support polio vaccination efforts [38], but it is doubtful if UN agencies alone can gain operational access and trust from all parties in conflicts. UN mandates and governance are indeed poorly adjusted to the fact that civil conflicts and public health crises are nowadays inevitably inter- twined. The WHO is constitutionally constrained by its al- legiance to Member States and cannot officially recognize opposition parties as operational partners. This is a problem in terms of neutrality, independence, legitim- acy and access in situations of civil war. In contrast,

some international humanitarian organizations have for- mal or informal legitimacy to operate regardless of polit- ical fractures and state funding. They cannot substitute for UN agencies, but their unequivocal neutrality and imparti- ality are assets to secure universal access to conflict zones and to remain credible. This is why the co-optation of hu- manitarian aid as an instrument of domestic security puts both humanitarian action and global public health initia- tives in jeopardy.

Interference of security agendas with humanitarian action The setbacks of the Global Polio Eradication Initiative in its final stage could have been anticipated precisely in those conflict zones where access and trust are para- mount. However, new counter-terrorism and foreign policies of Western coalitions are enmeshing humani- tarian action into international security agendas, which can discredit the neutrality of all humanitarian actors, for example when relief and health care are provided to secure the acceptance of counter-insurgency operations [39, 40]. The securitization of global public health and the militarization of humanitarian action reflect the dom- inance of post-9/11 doctrines in the global health regime, and both trends combine to compromise the success of the Global Polio Eradication Initiative. This political com- plexity is not acknowledged by the WHO. In her opening statement at the 67th World Health Assembly, Dr. Chan attributed the recent downturn of international polio control to: “Armed conflict that flies in the face of inter- national humanitarian law. Civil unrest. Migrant popu- lations. Weak border controls. Poor routine immunization coverage. Bans on vaccination by militant groups. And the targeted killing of polio workers” [41]. Ironically, just ahead of that opening session, the CIA implicitly ac- knowledged some responsibility by announcing that the

Table 1 Examples of securitization of global public health surveillance: typology

Governance level Securitizing agent Initiatives or projects Examplesa

Private Private philanthropy Sponsoring the establishment of global surveillance networks

1. Nuclear Threat Initiative

National USA (Security agencies, academia) Development of event-based surveillance technology

2. Project Argus

USA (Senate) Capacity building, conditional aid to developing countries

3. US Global Pathogen Surveillance Act (2007)

International USA (President) Political and technical alliance 4. Global Health Security Agenda

Some industrialised countries Political alliance 5. Global Health Security Initiative

Regional surveillance networks Coordination of regional surveillance networks

6. CORDS

Supra-national WHO Technical resources for event verification 7. Biological Weapons Convention

WHO/UNODA Technical support to the UN Secretary-General

8. Memorandum of understanding

aNumbered examples and additional references are summarised in Additional File 1

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agency was ending the use of vaccination programmes in its spying operations [42].

Global health governance after the Ebola epidemic A consensus has emerged to say that the disastrous situ- ation in Guinea, Liberia and Sierra Leone reflects the dis- array of national health systems and a vacuum in global health governance [43, 44]. With a much delayed and frag- mented regional response, the case is an archetype of the global health security regime in several respects. What ultimately triggered the international mobilisation of adequate resources was the realisation that the epidemic could easily spread out of Africa and represented a com- mon threat to international peace and security. In Septem- ber 2014, three major political decisions followed this reasoning. Firstly, the UN Security Council adopted Reso- lution 2177, acknowledging that the Ebola outbreak in Western Africa constituted a threat to international peace and security. Secondly, the US administration deployed some 3,000 military personnel in Liberia to reinforce outbreak-control measures. Although such an initiative was generally acclaimed as a valuable contribution to controlling a catastrophic situation, some scholars see it as yet another example of the militarization of hu- manitarian aid [45, 46]. Thirdly, a UN Mission for Ebola Emergency Response (UNMEER) was established in Ghana. Its regional mandate and authority are limited, but as the first UN emergency health mission, UNMEER might be- come a precedent for a new transnational outbreak govern- ance system, thus marginalising the IHR (2005) framework of non-binding recommendations. It is uncertain how the current global health security

regime will evolve [1], particularly after the epidemic cri- ses of 2014–2015. Notwithstanding an evaluation of the performance of the IHR (2005), the ‘reforms’ proposed by the WHO [47, 48] in the wake of the 68th World Health Assembly consist in: (i) integrating WHO out- break and emergency response units, (ii) the creation of a global health-emergency workforce, (iii) setting up an emergency contingency fund, and (iv) advancing the re- search and development of medical products for infectious diseases of epidemic potential, and (v) strengthening health systems. One could muse over the fact that such measures are belated, obvious or simply represent an attempt to res- urrect similar assets dismantled by a recent round of crip- pling reforms. More than with circumstantial resolutions, global health would be served by genuine reforms of the current regime, emphasizing universal health values in- stead of security and diplomacy interests. This would entail a new constitutional mandate for the WHO. Reflecting on the future of global health governance, Lawrence Gostin has called for a new Framework Convention on Global Health [49]. With a bold departure from the UN gov- ernance model, a new and more credible global health

regime could be built upon such a convention, by trans- cending narrow State interests. The core of this new architecture would make the WHO akin to the Inter- national Committee of the Red Cross with its supra- national mandate, with political independence and a better capacity to react to global health crises.

Summary The setbacks of the Global Polio Eradication Initiative and the delayed control of the Ebola epidemic in West Africa reflect a fragmented approach to outbreak pre- paredness. More broadly, they point to profound flaws in the current regime of global health governance, which is guided by foreign affairs and security policies. The securitization of communicable diseases has so far led for- eign aid policies to sideline health systems. It has also been the source of ongoing misperceptions over the aims of global health initiatives. With its strict allegiance to Member States, the WHO mandate is problematic, par- ticularly when it comes to controlling epidemic diseases. In this context, humanitarian medical organizations are expected to palliate the absence of public health services in the most destitute areas, particularly in conflict zones. The militarization of humanitarian aid itself threatens this fragile and imperfect equilibrium. None of the reforms announced by the WHO in the wake of the 68th World Health Assembly address these fundamental issues.

Additional file

Additional file 1: Examples of securitization of global public health surveillance: overview of selected initiatives or projects. (DOC 50 kb)

Abbreviations BWC: Biological Weapons Convention; CIA: US Central Intelligence Agency; COTPER: Coordination Office for Terrorism Preparedness and Emergency Response; IHR: International Health Regulations; UN: United Nations; UNMEER: UN Mission for Ebola Emergency Response; USA: United States of America; WHO: World Health Organization.

Competing interests Philippe Calain is a former staff member of the WHO and a former external member of the WHO Research Ethics Review Committee. He has participated in several advisory panels convened by the WHO Secretariat. Opinions and facts discussed in this paper are the result of personal and independent research, strictly based on publicly available information or published opinions. Caroline Abu Sa’Da has reported no conflict of interest.

Authors’ contributions PC and CAS both contributed to the conception of the work through frequent discussions. PC gathered the data and wrote the first draft. CAS critically revised the first and subsequent drafts of the manuscript. All authors read and approved the final draft.

Acknowledgements We wish to thank Maude Montani and Timothy Fox for proofreading successive versions of this manuscript, and Sarah Venis for editorial advice.

Funding No funding was received by the authors for the preparation of this paper.

Calain and Abu Sa’Da Conflict and Health (2015) 9:29 Page 5 of 7

Ethics review No ethics committee review of this article is required.

Received: 10 March 2015 Accepted: 11 September 2015

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