History of the Debate on Health Security

The role of infectious disease in modern security studies originates in the historical accounts of Thucydides, Machiavelli, and Rousseau, all regarded as republican progenitors of the political paradigm known as Classical Realism. Deudney has argued that Realism as a theoretical construct (along with its cousin Liberalism) is derivative of an earlier “republican” tradition, with both terms coined in the nineteenth century.1 Historians have continued this discourse on contagion into the modern era, noting the profound influence of pathogens on the course of history, and in certain cases the fate of countries.2

As was argued above, the republican political tradition (with its Realist and Liberal descendents) constitutes the theoretical antecedent for those political scientists who began their inquiries in the mid 1990s, including Dennis Pirages and the present author.3 Pirages was the first to assert that infectious disease constituted a direct threat to human security insofar as it places the security of individuals and communities over that of states:

Infectious diseases are potentially the largest threat to human security lurking in the post-Cold War world. Emerging from the Cold War era, it is understandably difficult to reprogram security thinking to take account of non-military threats. But a new focus that included microsecurity issues could lead to interesting costbenefit thinking. In the short term, policymakers need to understand the potential seriousness of the problem and reallocate resources accordingly.4

The nascent field of “health security” enjoyed a pronounced increase in salience during 2000, when the US National Intelligence Council issued a National Intelligence Estimate which concluded that infectious disease posed both direct and indirect threats to the material interests and security of the United States (Gordon 2000). In that report, the NIC stated:

New and reemerging infectious diseases will . . . complicate US and global security over the next 20 years. These diseases will endanger US citizens at home and abroad, threaten armed forces deployed overseas, and exacerbate social and political instability in key countries and regions in which the United States has significant interests.5

Subsequently, based on the recommendations of the National Security Council, the Clinton administration declared HIV/AIDS a threat to global security.6 On January 10, 2000, Vice-President Al Gore articulated the Clinton administration’s position that HIV/AIDS constituted a significant threat to global security in an address to the UN Security Council:

For the nations of sub-Saharan Africa, AIDS is not just a humanitarian crisis. It is a security crisis—because it threatens not just individual citizens, but the very institutions that define and defend the character of a society. This disease weakens workforces and saps economic strength. It strikes at the military, and subverts the forces of order and peacekeeping. AIDS is one of the most devastating threats ever to confront the world community. Many have called the battle against it a sacred crusade. The United Nations was created to stop wars. Now, we must wage and win a great and peaceful war of our time—the war against AIDS.7

Such perceptions of the gravity of the AIDS crisis persisted into the early months of the George W. Bush administration, and were echoed by Secretary of State Colin Powell on June 25, 2001 in an address to the UN General Assembly. Powell also framed the issue as one of national security: “I was a soldier and I know of no enemy in war more insidious or vicious than AIDS, an enemy that poses a clear and present danger to the world. . . .”8 Under-Secretary of State Paula Dobriansky concurred: “HIV/AIDS is a threat to security and global stability, plain and simple.”9

On July 17, 2000, under the leadership of US Ambassador Richard Holbrooke, the UN Security Council adopted Resolution 1308 (2000), which explicitly declared the HIV/AIDS pandemic a threat to global security. This was the first time (in the modern era) that an issue of public health had been elevated to such status, and it illustrated the continuing transformation in thinking about new threats to security in the new millennium. This recognition of the centrality of health to issues of power and security was profoundly disturbing to the Galenists who had worked for decades to create the false dichotomization of health and security.

Regrettably, this dramatic resurrection of the salience of global public health issues, and their influence on security debates, was subsequently derailed by several factors. First, the attacks of September 11 fundamentally transformed the intellectual space of the post-Cold War security rubric, as terrorism was thereafter defined as the principal and immediate direct threat to the security of the United States. Unfortunately, the human tendency to fix on one proximate threat while ignoring others, so dominant during the Cold War, rose to the fore again in the post-9/11 era. Other process-based threats, including environmental destruction, resource scarcity, and contagion, were shunted aside. The novel terror-induced myopia that gripped Washington was further augmented by the anthrax attacks. These biological attacks in particular succeeded in framing the health-security debate primarily through the lens of bioterrorism, and US funding became increasingly directed toward biodefense initiatives (e.g., Biowatch and Bioshield) and away from investments in basic public health infrastructure. In addition, longsimmering tensions between Secretary of State Powell and Secretary of Defense Rumsfeld resulted in the gradual marginalization of the Department of State, of its key players, and of its more nuanced and holistic conceptualizations of global security, which included threats to public health.

In 2002, several political scientists (Elbe, Ostergard, Peterson, Price-Smith, Singer) analyzed the validity of the hypothesis that infectious disease represented a security concern. Within this larger debate, the threat posed by HIV/AIDS has received the greatest amount of attention, producing much heat and some light. Stefan Elbe argued, convincingly, that the deliberate transmission of HIV, through the horrid practice of war-rape, was widely employed by military forces throughout subSaharan Africa.10 Robert Ostergard exposed the palpable Western ethnocentrism of security studies, and argued that infectious disease constituted a significant direct threat to the security of numerous polities throughout the developing world.11 Peter Singer argued that “the looming security implications of AIDS, particularly within Africa, are now a baseline assumption. AIDS not only threatens to heighten the risks of war, but also multiplies its impact.”12 Susan Peterson examined the claims of health security theorists and concluded that they possessed a certain degree of validity, although she argued (correctly) that disease had a greater potential for the internal destabilization of states than for fomenting wars between sovereign states.13

In 2003, the RAND analysts Jennifer Brower and Peter Chalk also noted the insidious nature of the disease threat to US national security. They argued that “disease acts as a highly pervasive influence that not only impinges on security in terms of traditional conceptions of state stability, but, more insidiously, directly undermines and weakens the essential socioeconomic foundations upon which an effective polity ultimately depends.”14 Therefore contagion might operate to destabilize those poorer countries that exhibit low levels of capacity, and the resulting negative externalities might then radiate on a regional and global scale, undermining the interests of the great powers.

The SARS epidemic of 2002-03 certainly had the biological potential to evolve into a security threat, and that potential was perceived by China’s political elites (Huang 2003). After the SARS scare, linkages between HIV/AIDS, domestic level governance, and security were explored,15 and sporadic attempts to link infectious disease and security have followed in recent years.16 Unfortunately, advocates of the health and security debate have recently encountered resistance from the Galenic community and from orthodox security theorists who remain wedded to the “guns, bombs, and terror” paradigm and reject unconventional process-based threats such as environmental destruction.17

On Health and Power

The historical literature clearly indicates that the policy elites of earlier generations understood the connectivity between the health of the population and the prosperity, cohesion, and power of the state. The concept of political power was effectively articulated by Hans Morgenthau: “When we speak of power we mean man’s control over the minds and actions of other men. By political power we refer to the mutual relations of control among the holders of public authority and between the latter and the people at large. Political power is (therefore) a psychological relation between those who exercise it and those over whom it is exercised.”18

If disease is the antithesis of health, then periodic manifestations of contagion should, logically, impoverish and destabilize the state and diminish its power relative to unaffected polities. Variance in the magnitude of such disruption is dependent on several things, including the lethality and transmissibility of the specific pathogen, the capacity and resilience of the state, and the human ecology of the affected society (including levels of acquired immunity). Thus, it is not surprising that population health was understood as a central component of state power, and particularly hard power, which explains the development of contagionist practices to counter the ineffective practices of the Galenic school. Thus, the policy community has correctly regarded infectious disease as corrosive of socio-political cohesion, economic prosperity, and puissance.

The concept of power (in the domain of health and security) possesses two faces, with the first face being the power of the state with respect to the population over which it presides. As was argued above, contagion may produce disintegration of social capital and cohesion, a rise in identity-based violence between factions (based on ethnicity or class), and an erosion of domestic productivity and prosperity, that collectively threatens the material interests of political elites and the integrity of state institutions. Consonant with the dictates of contagionist doctrine the state (in order to preserve order, its material interests, and its survival) may consequently engage in coercive practices against its own people. Such abuses of power by the state against society are well documented herein, ranging from the draconian practices of the Mantuan and Florentine lords to the Medizinalpolizei of Imperial Prussia, and in modern times, the Mugabe regime in Zimbabwe.

The second face of power emanates from the material reality that manifestations of epidemic disease clearly have the ability to weaken a state relative to its sovereign rivals. Epidemics may visit destruction on a state’s apparatus of coercion (military and police forces), kill important personnel in the bureaucracy, constrain and erode economic prosperity and thereby diminish the base of tax revenues, and undermine the cohesion of the state. Collectively, these effects will vary according to the particular attributes of the pathogen, immunity of population, state capacity, co-infection, and even geography.19 For example, a state that is simultaneously burdened by a number of various pathogens (say, malaria, HIV, and schistosomiasis) that afflict a significant proportion of the population (>20 percent per annum) will be much weaker than a state in which similarly malign pathogens are less prevalent and the burden of disease is therefore much lower.20 Thus, over the decades, the power of the second state relative to the first will increase substantially.

Thucydides clearly understood this negative association between disease and power. The arrival of “the plague” clearly undermined the socio-political cohesion of the Athenian polity, generated lawlessness and disorder, and destroyed circa 30 percent of the empire’s infantry. The contagion resulted in the death of leading members of the state, most notably Pericles, after which the rise of demagogues led eventually to the defeat of Athens. Machiavelli’s account of the Black Death as it visited Firenze (Florence) also illustrates the destructive effects of the plague on effective governance and social cohesion.21

Thus, modern conceptualizations of health and security emanate from the republican political tradition, and its descendent Realism, which emphasizes state survival through the maximization of power. Realist theory stipulates that the state will act in its own material self-interests, or in the interests of those dominant factions that constitute and/or control the machinery of the state. The theory also assumes that the international system is anarchical, and that the condition of competitive anarchy precludes significant cooperation between states unless such cooperation is in their own material and/or ideational self-interest. This hegemonic theory explains the evolution of international public health regimes (such as the International Health Regulations) as purely derivative of the material interests of the great powers.22 Hegemonic theories of regime formation and evolution also help to explain the rapid revision of the International Health Regulations in the wake of SARS. Given that health was historically recognized as a fulcrum of state power, and subsequently as a tool of imperial expansion, international health regimes followed in order to perpetuate the dominance of the powers that had crafted them. The medical historian George Rosen argues that during the era of mercantilism, wherein the consolidation of the modern state took place, “the welfare of society was regarded as identical with the welfare of the state.” He continues:

Since power was considered the first interest of the state, most elements of mercantilist policy were advanced and justified as strengthening the power of the realm. Raison d’etat was the fulcrum of social policy. As the rulers and their advisers saw it, what was required was first of all a large population; second, that the population be provided for in a material sense; and thirdly, that it should be under the control of government so that it could be turned to whatever use public policy required. (I)t was recognized everywhere in some degree that effective use of population within a country required attention to problems of health.23

In the early to mid 1600s, the collection of data and the use of science (including medicine) to bolster the power of the state was the domain of “political arithmeticians” such as William Petty and John Graunt. They used the emerging science of statistics to quantify the burdens of illness to the economy and state power.24 In the 1620s, Prussia’s political elite explicitly recognized the centrality of population health to state power and established the Medizinalpolizei (medical police). From 1655 on, the association between health and power was promulgated throughout Prussia by the political administrator Veit Ludwig von Seckendorff. According to von Seckendorff, the state was obliged to establish laws to ensure the well-being of the population, such that their number and the productivity of the citizenry would increase, generating prosperity and thus puissance for the nation.25 The historian John Hays concurs:

Early modern European states gradually came to recognize connections between the size of their populations and both military power and economic prosperity. . . . Enlightened despots of the same period embarked on programs of “medical police,” particularly attending to the control of epidemics through isolation and quarantines. . . . The concern that eighteenth-century states manifested for the health of their soldiers and sailors suggests the importance of the military motive for such benevolent behavior.26

It was during this period that medicine and public health, with their increasing capacity to control disease, became effective tools of imperial expansion for the European powers. Medical and sanitary advances augmented the ability of European forces to withstand hostile foreign disease environments. Such technological advances also conferred symbolic and psychological advantages on European forces: they were perceived as masters over illness. The demographer Philip Curtin posits that European forces benefited enormously from this “revolution in tropical medicine and hygiene,” which permitted and augmented an unprecedented projection of European power into tropical regions.27 This association between health and hard power intensified in the aftermath of the Franco-Prussian War as universal conscription became ubiquitous throughout the European states. Thus, a direct and positive association emerged between the sheer size of the population, their health and productivity, and the projection of martial power.28

Moreover, the domestic institutional architecture created by states to contain epidemic disease during the early years of the Westphalian era (1648-present) suggests a desire to preserve both societal order and state power through legal mechanisms of disease containment. Such mechanisms included the Bavarian law that made smallpox vaccination compulsory in 1807—a law that was emulated by Denmark (1810), Russia (1812), and Sweden (1816).29 Britain enacted similar health regulations to preserve state power and prosperity—notably the Contagious Diseases Acts of 1864,30 which “licensed and controlled prostitution in an attempt to preserve the health of the military.”31

(Re-)Defining Security

Given the centrality of health to the cohesion, wealth, and power of the state, widely accepted by political elites in prior generations, why should health have been de-securitized in the modern era (1945-present)? Opponents of the “health and security” paradigm approach the issue as if the association had simply appeared ex nihilo, ignoring the wealth of historical sources that document the lineage of the relationship.32 However, the securitization of health is not novel at all, but hearkens back to a classical (republican) vein of thought that pervades the discipline of political science and its various subdisciplines.33

In 1983, the political scientist Richard Ullman redefined security in a manner that transcended those modern Realist definitions that focus exclusively on military threats, arguing that “defining national security in purely military terms conveys a profoundly false image of reality [and] causes states to concentrate on military threats and to ignore other and more harmful dangers.”34 Further, Ullman defined a threat to national security as “an action or sequence of events that (1) threatens drastically and over a relatively brief span of time to degrade the quality of life for the inhabitants of a state, or (2) threatens significantly to narrow the range of policy choices available to the government of a state or to private, non-governmental entities (persons, groups, corporations) within the state.”35 This redefinition of security is useful in that it includes material-contextual factors, and thus non-military threats—e.g., the destruction of a state’s population by a pathogenic agent such as avian influenza, or the human immunodeficiency virus (HIV). Furthermore, Ullman’s definition places emphasis on processes as threats, not just on human enemies. This represents an important intellectual advance because processes can compromise security over very long periods of time, and are therefore rather difficult to observe. As a species, humans suffer from a truncated attention span, and an event (e.g., a bombing in the London subway) is sure to capture the attention of the global media, and thus policy elites. Attenuated processes (e.g., global climate shifts or HIV-induced destruction of populations) are much more difficult to observe. Such malignant processes suffer from reduced saliency until some critical threshold (or tipping point) is reached, whereupon macro-level non-linear destabilization occurs and the media and policy makers are forced to deal with the issue. The emergence of the hole in the ozone layer over the Antarctic region illustrates this problem. In this particular case, satellite-procured data on stratospheric ozone concentrations was delivered to an array of sophisticated computers for analysis. The computers were programmed to detect linear changes in the concentration of ozone, such that when rapid and non-linear decay in the ozone layer was observed, it was dismissed by the computer programs as an error in the data and disregarded for several years.36

A second challenge to orthodox militaristic conceptualizations of security came from Barry Buzan, who argued that national security encompasses various spheres of activity including military, economic, political, societal, and environmental dimensions.37 Furthermore, he understood the complex and interactive effects that each domain could exert on the others, and therefore his conceptions are holistic. Buzan argued that “individual national securities can only be fully understood when considered in relations both to each other and to larger patterns of relations in the system as a whole.”38

Additional challenges to the militaristic paradigm came from Edward Kolodziej39 and from Kalevi Holsti. Holsti expressed dismay at the discipline’s pronounced dislocation from the empirical reality faced by the majority of countries, echoing claims of disciplinary ethnocentrism.40 According to Holsti, “strategic studies continue to be seriously divorced from the practices of war. . . . The argument . . . is that security between states in the Third World . . . and elsewhere has become increasingly dependent on security within those states. The trend is clear: the threat of war between countries is receding, while the incidence of violence within states is on an upward curve.”41 Therefore, endogenous threats42 to prosperity, cohesion, and power may in fact present greater threats to many countries than the martial power of their contiguous neighbors.

The emergence of the environmental-security debate in the early 1990s provided for additional definitions of security that departed from the orthodox military-centric viewpoint.43 Indeed, early conceptualizations of the health security paradigm noted the profound connectivity between environmental change and pathogenic emergence, proliferation, and mutation (Price-Smith 2002). The destruction that Hurricane Katrina visited on New Orleans (and proximate areas) in 2005 exposed the vulnerability of the sovereign state, and the people it is obliged to protect, to non-military threats. Despite the policy-making community’s increasing recognition of naturally occurring threats to the state, the academic community has been exceptionally slow to recognize the threat posed by such material-contextual phenomena, which include infectious agents.

Issues of public health, then, exhibit a significant impact on the state precisely because of their historical relations to power and order, and because diseases have the potential to kill a great proportion of the population, deplete state coffers, destabilize the polity, and weaken the state relative to its rivals. An infectious disease may constitute a direct and/or an indirect threat to a state’s coherence, prosperity, and power. Thus, it is entirely logical to extol the virtues of investing in population health and, simultaneously, to maintain a republican state-centric view of security. The state is thus motivated by enlightened self-interest to protect its power base, which by extension entails protecting the health of its people from pathogens.

The modern health-security debate remains impoverished on several counts. First, the arguments against securitization presented by Roger Cooter and others are often profoundly ahistorical and largely ideological. Moreover, the current debate over the securitization of infectious disease (most of which focuses on the HIV pandemic) appears to begin in the late 1980s, after the diagnosis of AIDS. The imposition of such severe temporal restrictions on the debate results in a discourse that largely ignores the connectivity between infectious disease, governments and their constitutive institutions, and civil society over thousands of years of recorded history. The ignorance of basic principles of public health, epidemiology, and microbiology by certain social scientists participating in the debate is also deleterious to the construction of any serious debate of the issues. Similarly, the ignorance of political and economic thought by many in the medical community limits thoughtful debate on the issue. In addition, the securitization of disease should in no way be focused exclusively on the effects of one pathogen, even one as pernicious as HIV. There are many pathogens that possess the capacity to inflict great physical harm on a population (particularly influenza), and which also threaten economic productivity and global trade (e.g., SARS). To limit the debate to HIV/AIDS excludes an entire spectrum of other possible threats to prosperity, stability, and power, and it is analytically problematic.

Furthermore, the designation of a pathogen as a threat to “health security” will vary to some degree from one sovereign entity to another, as different polities will exhibit different vulnerabilities, based on the population’s genetic or acquired resistance levels, state capacity, geographic location, etc. Thus, the Western bias of the security literature is problematic, such that a phenomenon is typically not seen as a threat to national security unless it constitutes a threat to the security of the hegemon (in this case, the United States). The abstract concept of health security should surely apply to all sovereign states. Thus, it is nonsense to say that a pathogen does not qualify as a threat to the security of a country simply because it is not a direct threat to the United States, and such discourse reflects both Western hubris and muddled thinking. If an epidemic were to break out in a country that possessed low capacity, and therefore low resilience, and overwhelm the population, it might indeed constitute a direct threat to that country’s security. However, that same pathogen might not represent a threat to a member of the G-8, whose members possess significant endogenous capacity, and a different configuration of the human ecology. Thus, it seems reasonable to postulate that a pathogen such as HIV constitutes a qualitatively greater threat to the least-developed countries that possess less resilience.

Conversely, certain pathogens possess various genetic attributes and adaptations that allow them to thrive in the environments of the developed world but not in impoverished environments. For example, SARS presented a clear threat to China and Hong Kong (and Canada) because it thrived within the air conditioning and sanitation systems of modern buildings, whereas it was easily contained in the low-tech but open-air hospitals of Viet Nam.44 Therefore, prosperity (in the form of high-tech buildings equipped with air conditioning can, in perverse fashion, enable different pathogens that thrive in those particular ecological niches. Ultimately, the security calculus must be pathogen-specific, moderated by a country’s capacity and ecological configuration.

Moreover, as Marshall McLuhan predicted, advances in technology, such as the increasing speed of travel and telecommunications, have created a “global village.”45 These accelerating processes of “globalization” have greatly increased the scale of connectivity between the developed and the developing countries, such that destabilization in one country can trigger a non-linear global chain reaction of disruption. The Asian financial crisis of 1997 is an excellent illustration of such global connectivity, as the economic destabilization of Thailand ultimately led to profound turbulence in the markets and economies of distal countries, including Russia and Brazil. In the domain of infectious disease, this means that the emergence of a new lethal pathogen in South Asia (e.g., SARS), can trigger fear and anxiety, leading to the rapid destabilization of markets throughout the Pacific Rim.

Further, as September 11 illustrated quite vividly, instability in the developing countries can directly affect the security interests of the developed countries. If disease stresses the capacity of a polity, it may interact with other variables in complex and non-linear fashion to contribute to the erosion of effective governance, resulting in weak or collapsed states. Furthermore, if a pathogen destabilizes the economy and political cohesion of a certain country, the collapsed state may subsequently generate externalities that indirectly undermine the interests (and the security) of the great powers. Weak and collapsed states are breeding grounds for the disaffected and may become harbors for radical groups (such as AlQaeda) seeking to inflict destruction on the dominant sovereign states. In this fashion, disease-induced instability in developing countries may indirectly threaten the national security of many developed states (including the United States).

There is evidence that disease may certainly facilitate internal turbulence, but is there solid evidence that imbalances in power generated by contagion will produce war between sovereign states? To date, the balance of evidence suggests that there appears to be no positive association between the incidence of disease and subsequent war between sovereign states.46 Despite the Realist axiom that asymmetries or shifts in relative power between sovereign states contribute to conflict between those powers, this association does not appear to hold when one state is severely afflicted by disease. One explanation for this is that pathogens may afflict geographically contiguous states to an equivalent extent, and contagion appears to have a sclerotic or paralytic effect on both societies and the institutions of the state (including the apparatus of coercion). Therefore, in the face of contagion, the state’s institutional capacity to act in a bellicose manner is consequently reduced, even though the relative power of country B may begin to exceed that of country A as a result of the contagion. Second, if country A is besieged with contagion and country B is less afflicted, it makes little rational sense for country B to invade country A and thereby expose its soldiers to the epidemic, taking the additional risk that said troops could then bring the pathogen back to country B on their demobilization. Thus, epidemic disease may significantly inhibit the operational capacity of military units, generate the rational calculus that conflict should be avoided, and thereby force a cessation of hostilities or inhibit the initiation of conflict. In that manner the war/disease relationship may operate on occasion as a negative feedback loop wherein military conflict initially acts as a disease amplifier, and thereafter the spread of infection within military units intensifies until they lose the capacity to prosecute their campaigns.

Republican Realism

. . . the central theme of international relations is not evil but tragedy.

—Robert Jervis47

Given that modern strains of Realism are the descendents of republican political thought, I argue for a republican revision of Realism. Realism’s historical focus on survival, (which emanates from republican theory) as the ultimate goal of the state remains in effect, as all states seek to perpetuate their existence to some degree. The quest for survival therefore entails the maximization of power, in order to dissuade other competitors from undertaking hostile action against the state. This maximization of power entails the protection of the people, from whom the state derives its prosperity and its military power. Indeed, prosperity is central to military power, as economic assets are fungible and may be readily translated into purchases of advanced weapons systems, training of skilled personnel, and materiel. The protection of the people from pathogens is also central to the maintenance of order within the polity, ensuring that state institutions continue to function with a moderate degree of efficacy and that the state and the society do not fragment internally.

However, the utility of certain tenets of modern Realism must now be questioned. First, as the political scientists Graham Allison and Randall Schweller concede, the state is not a unitary, monolithic actor,48 as various factions (i.e., interest groups) or organizations within the state (i.e., bureaucratic divisions) compete for fiscal resources and to project their particular interests during the processes of foreign policy formation.49 The second major shortcoming of the Rational Actor Model is that it assumes that a state acts (as one entity) to make the most rational decisions possible, therefore maximizing its power and its interests. Such assumptions of rationality are certainly questionable in the domain of health and foreign policy, and the political scientist Stephen Walt has extensively criticized assumptions of rationality in game-theoretical decision making.50

As seen throughout the case studies, the assumption of rational maximization of utility by the state, in dealing with other international actors and/or dealing with its own population, is questionable. In the cases of BSE, SARS, and HIV/AIDS, sovereign states have engaged in trade embargoes driven by fear and uncertainty, have restricted the movements of both trade goods and human personnel, have sought to obscure the magnitude of contagion from the international community, have denied the problem, and have resisted cooperating with other international actors until compelled to do so. The case of the 1918 pandemic influenza is difficult to characterize, as the war precluded cooperation between many of the infected parties and the protagonists applied draconian restrictions on reporting the contagion. However, even among non-combatants there was little cooperation on the issue, although this probably was due to the fact that medicine and public health were incapable of providing effective prophylaxis, let alone treatment.

As I argued above, psychological elements, such as perception (or misperception), emotion, concepts of group identity, and image theory, have figured in the evolution of epidemics and in the magnification of their associated externalities. Such a republican revision of Realism echoes the work of Robert Jervis, who, as a proponent of Realism, nonetheless realized the importance of psychological effects on the (mis)perceptions and calculations of policy elites. It is imperative to recognize that the empirical biological reality of epidemics is moderated by perceptions, by affect (emotion), by concepts of identity, and by bounded rationality. Only when we begin to engage in a republican synthesis of the paradigms of Realism and political psychology do we gain any significant analytical traction in the realm of health and security studies. The trans-national character of the threat complicates our ability to perceive it accurately, and the uncertainty associated with novel pathogens complicates our assessment of the risk. This makes it exceedingly difficult for political elites to gauge the level of the threat accurately.

The globalization of pathogens generates additional complexities for orthodox conceptualizations of Realism, which stipulates that states will engage in strategies of self-help to contain pathogens within their borders. Such containment may require sealing borders to trade and migration, mass quarantining of infected individuals, and continued effective surveillance. Obviously, many states (including the US) lack the endogenous capacity for surveillance, diagnosis, effective prophylaxis and treatment, and means of quarantine and border control. That said, states may thus find it expedient to engage in compacts to provide mutual assistance as based on their perceived self-interest. In this sense, the emergence and evolution of global health regimes merely reflects the historical interests of the hegemonic power (or a coalition of great powers) in containing those specific pathogens that threatened the interests of those states. Thus, the threat of contagion establishes the republican basis for inter-state cooperation as a means to protect the material interests of all states.

Republican theory permits the reform of Realism to explain the behavior of states in the domain of infectious disease. First, we must abandon assumptions of the state as a unitary actor. As witnessed in the case of China during the SARS scare, different segments of the bureaucracy impede the effective flow of information to the apex of government. Further, competition between domestic institutions certainly undermined rational responses by federal governments in the case of BSE, ranging from the persistent incompetence of the Ministry of Agriculture, Fisheries and Food in Britain to the influence of domestic agricultural lobbies on the efficacy of the Department of Agriculture in the United States. Moreover, despite the rhetoric of free trade in the modern era, the BSE crisis has served as an excuse for protectionist behavior.

Furthermore, decision makers exhibit bounded rationality, which stipulates that they will attempt to make the most rational decision possible but face considerable constraints.51 Such constraints include serious difficulties in the estimation of risk, particularly in the face of a novel and emergent pathogen of unknown etiology and lethality. Time constraints will also limit the generation of accurate information regarding the etiology, lethality, and transmissibility of said pathogen, further impeding optimal decision making. Such limited information results in significant uncertainty, which in turn can generate significant manifestations of anxiety, even fear, and which often leads to overreaction. As Jervis argued, the incapacity to perceive threats accurately often leads to Pareto-suboptimal decision making.52 Conversely, decision makers may also seek cognitive consistency (by reinterpreting or disregarding information that conflicts with their existing belief structures), and may engage in excessive minimization or denial of a threat.53 Furthermore, humans exhibit the tendency to perceive threats as “enemies” and not as “processes.” Security theorists should be aware of such cognitive biases and should understand that threats to both national and international security can take the form of long-term, complex, and non-linear processes.

A republican reformation of Realism maintains that sovereign states remain the dominant actors in the system, and that international regimes (e.g., the IHR) merely reflect the power and interests of a dominant state or coalition of states. However, republican Realism notes that threats to security can emanate from non-military sources, such as non-state actors (terrorists), or from processes such as pathogenic emergence. Moreover, the Realist dichotomization of the domestic and systems levels of analysis is problematic, given that the breakdown of governance within a sovereign state can generate radiating externalities that compromise the security of proximate states. The discipline of security studies must abandon its ethnocentrism and recognize that the immiseration of peoples in the developing world, and the collapse of governance therein, presents a novel threat to the security of the developed nations as well. Thus, republican theory, with its emphasis on physis, embraces the concept of complex interdependence in the human ecology, and notes that the natural world maintains a profound capacity to influence the conduct of human affairs.

Mechanisms

In sum, infectious disease operates in a number of ways to destabilize a state from within or to weaken a state to the extent that its ability to project power, and indeed to defend itself, is significantly compromised. The balance of evidence suggests that contagion does not start wars between sovereign states (although it does seem to possess the historical capacity to immobilize military forces, and could thereby result in a cessation of hostilities).

At the domestic level, infectious disease acts to undermine state capacity, and therefore the stability of the polity, through the following mechanisms:

Mortality and morbidity Disease-induced death and debilitation deplete the endogenous base of human capital, undercut the productivity of workers, and generate negative effects at the micro, sectoral, and macro levels of the economy. The destruction of the population also compromises military recruitment, and generates the loss of skilled personnel. Declining ingenuity Disease-induced erosion of human capital limits a society’s capacity to generate ingenuity, eroding downstream social and technical innovation, impeding economic productivity, and undercutting the state’s resilience (ability to respond to crises).

Diminished revenue Disease-induced declines in productivity result in economic contraction that will consequently limit the tax revenues and other resources that are extracted from the people by the state. As the tax base erodes, the capacity of the state to provide public goods for its own citizens declines correspondingly, as does its ability to project martial power.

Reduced social capital Disease generates in/out group behavior, results in the stigmatization of infecteds and/or vectors, and generates hostility between ethnic groups and/or classes. This generates destabilization within the polity and thereby undercuts the stability of the state as a macro entity.

Reduced legitimacy Widespread contagion may induce economic contraction, and cause the provision of public services to decline.54 State institutions may become increasingly brittle and sclerotic. The people may then see the state as ineffective and in violation of the social contract. Collectively, this may foster perceptions of the state as increasingly illegitimate, and thereby exacerbate internal social destabilization. Ultimately, the state may retaliate in draconian fashion against its own people (as in modern Zimbabwe).

Changes in relative power The destruction of important personnel throughout the bureaucracy, and the apparatus of coercion (i.e., the military and police forces), will jeopardize the state’s ability to protect itself from external aggression. Further, the erosion of the state’s fiscal resources will limit its ability to project power abroad and its ability to defend itself in the face of aggression. Such changes in relative power may affect downstream relations between states after the contagion has passed.

Connectivity As a result of the increasing interdependence resulting from accelerating globalization, the interests of the great powers are now profoundly linked to processes and events occurring in developing countries, such that destabilization of a polity in Central Asia can lead to externalities that directly affect and undermine the security of the United Kingdom. Thus, disease-induced destabilization in one region may compromise the prosperity and the security of all.

Furthermore, I argue, certain pathogens constitute significant and perhaps imminent threats to security, whereas other agents do not. For example, the re-emergence of a devastating H1N1 influenza virus, which in 1918 killed 50 million people, crippled armies, destabilized economies, and contributed to sclerotic governance, surely constitutes a direct threat to all countries. Globalization may, in fact, result in a pandemic of even greater scope and perhaps even greater lethality. On the other end of the spectrum is Lyme disease, which is endemic, is not transmissible from human to human, and often can be treated by antibiotic prophylaxis. I find it inconceivable to argue that Lyme disease constitutes a threat to the security of any polity. The following criteria constitute benchmarks for evaluating whether a pathogen constitutes a “security” threat to a given sovereign state:

• The negative health effects produced by the pathogen induce a minimum 1 percent/annum drag on the national GDP.

• The pathogen accounts for the mortality of 1 percent of the total adult population (15-55 years of age) per annum.

• The pathogen results in the severe debilitation of 10 percent of the total adult population per annum.

Doubtless, these criteria will provoke enormous debate among the “health and security” community, and that is my intent.55