Introduction
Following its response to the 2003 severe acute respiratory syndrome (SARS) crisis and the publication of the revised 2005 International Health Regulations (IHRs), the World Health Organization (WHO) gained new powers to declare a disease outbreak a Public Health Emergency of International Concern (PHEIC). This declaration gives the WHO the ability to securitise infectious disease outbreaks.Footnote 1 Declaring a PHEIC communicates to countries around the world that a disease outbreak represents an extraordinary event and a public health risk,Footnote 2 bringing into play the use of extraordinary measures, including increased disease surveillance, quarantine, border closures, the invocation of pandemic preparedness plans and the emergency use of novel vaccines or therapeutics.Footnote 3 This declaration also generates increased levels of urgency and support from the international community, including financial resources, enhanced diplomatic efforts, and security.Footnote 4
This article investigates three cases in which the WHO has declared a PHEIC. It looks at the H1N1 outbreak of 2009, the Ebola outbreak that occurred in West Africa from 2014–16 and the ongoing outbreak of coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It analyses these cases in terms of the declaration of a PHEIC and the securitisation of each outbreak and the response. In doing so, it engages with work focused on the securitisation of infectious disease that has increasingly highlighted the way in which this process occurs along a continuum and emphasises the significant role that evidence now comes to play in the (de)securitisation process.Footnote 5
Thinkers within this field have set out to explore with greater precision how evidence within certain contexts promotes, fosters, or limits a specific outcome of securitisation.Footnote 6 This article contributes to this endeavour via an investigation into these three cases and the combined role that global surveillance networks and genetic technologies played in the declaration of PHEICs. It argues that the securitisation of these outbreaks was dependent upon global and regional surveillance networks that utilised genetic technologies to make visible and intelligible the molecular characteristics and spread of the threat in question. In other words, they facilitate the creation of viruses as a threatening object to be securitised.Footnote 7 In 2009, genome sequence data was used to reveal the unique and ‘untypable’ nature or inherent characteristics of this swine flu virus. In 2014, reverse transcription polymerase chain reaction tests (RT-PCR) were used to make intelligible the widespread prevalence of Ebola across the population of West Africa. In 2020, a combination of RT-PCR tests and genome sequence data were used to reveal the unique nature of SARS-CoV-2.
Drawing from the literature focused on the role of science in securitisation efforts, this article demonstrates the power that genetic evidence exerts in the process through which infectious diseases are securitised. This power draws from a social perception of science as producing technical expertise and objective ‘facts’Footnote 8 about the world that objectivise – define and categorise – their objects of concern. The effect is not only that political issues can be depoliticised but that political actors can also be empowered in the implementation of their security agendas via the mobilisation of these facts.Footnote 9 In the cases of H1N1, Ebola, and SARS-CoV-2 genome mapping and RT-PCR tests revealed the novel molecular characteristics and spread of these viruses across various populations. This objectification led to their categorisation and securitisation in terms of the threat that they posed to the health of the international community. In all three cases the WHO Director-General and the Emergency Committee mobilised this ‘objective’ evidence to support their securitisation decision.
The result is an investigation that advances securitisation theory by demonstrating the way that evidence of the nature and spread of these pathogens provided by genetic technologies and gathered by fixed surveillance networks now plays a necessary and indispensable role in the securitisation of infectious disease outbreaks. There is, of course, no direct causal mechanism between the use of genetic technologies, the objectivation of scientific objects, the mobilisation of scientific ‘facts’ and successful securitisation.Footnote 10 Yet, the scientific evidence provided by genetic technologies now plays a necessary role in the declaration of PHEIC by the WHO and the securitisation of infectious disease outbreaks.
This argument is set out in the following steps. The first section details the way in which the securitisation theory of the Copenhagen School has been extended and adapted in its application to the study of infectious disease outbreaks and scientific evidence. In this application, scientific evidence is highlighted as having particularly powerful effects in shaping the securitisation of disease outbreaks. The second section details the WHO's response to the SARS outbreak and the new set of IHRs that would give the WHO increasing powers to categorise disease outbreaks as international emergencies and securitise them in response. The next section investigates the field of surveillance studies and the global networks supported and developed by the WHO to gather information on disease outbreaks. Focusing mainly on influenza, these fixed networks contrast with liquid forms identified in this area. They gather, analyse, and share physical samples in real time and make visible the genetic sequence data on emerging viruses. This data facilitates the creation of disease as a securitised object by identifying viruses with pandemic potential and it is also used to develop RT-PCR tests to aid diagnosis and population surveillance efforts. The final three sections detail the sole and combined role that genetic sequence data and RT-PCR tests played in the securitisation of the three outbreaks noted above. The conclusion details the wider implications that this analysis has on our understandings of securitisation outside of European and North American contexts.
Securitisation theory and infectious disease
The securitisation theory of the Copenhagen School analyses the application of a securitising logic that runs across different sectors.Footnote 11 Though not without criticism,Footnote 12 this approach frames security as an intersubjective field of social interaction with a specific set of actions and codes that are known by a set of agents in this field.Footnote 13 Security problems not only undercut the ‘normal’ political order but are often initiated by states that can then claim a special right of exceptional and extraordinary action.Footnote 14 The internalist reading of this approach emphasises the role of the speech act. Political elites have the ability to declare an issue to be a security concern. A securitising speech act is successful when its demands follow the accepted grammar of security, the securitising actor has sufficient authority to make the statement, the threat stated has features that either support or impede securitisation and the relevant audience accepts the claim and the issue as such a threat.Footnote 15 In addition to a securitising agent and a receptive audience, securitising moves also often require a threatening object to be securitised.Footnote 16
Applying this approach to the securitisation of infectious disease in the international arena, Colin McInnes and Simon Rushton have identified in the securitisation of HIV/AIDS a much more nuanced process. Drawing from Thierry Balzacq, these authors have argued that in this case, the process of securitisation represents a continuum and that empirical evidence plays a more significant role than previously argued and understood.Footnote 17 For Balzacq and his externalist and sociological reformulation of securitisation,Footnote 18 this approach is best utilised as a strategic (pragmatic) practice that occurs within, and ‘as part of, a configuration of circumstances, including the context, the psycho-cultural disposition of the audience, and the power that both speaker and listener bring to the interaction’.Footnote 19 This strategic practice is aimed at convincing a target audience to ‘accept, based on what it knows about the world, the claim that a specific development (oral threat or event) is threatening enough to deserve an immediate policy to alleviate it’.Footnote 20 By emphasising these elements of securitisation theory, Balzacq places securitisation in its social context, recognising the intersubjective field of power struggles that surround it and that the securitising actors and audience find themselves within.Footnote 21
Balzacq's position emphasises the use of securitising language in alignment with an external reality and context that is of concern to a particular audience.Footnote 22 Crucially, this external context and reality is also independent from the use of language.Footnote 23 For McInnes and Rushton this is important as it ‘opens the door for empirical “evidence” in support of the securitising claims to play a much more significant role’.Footnote 24 These authors note that the types of evidence required will depend upon the types of securitising claim being made. In the securitisation of HIV/AIDS such claims were linked to the evidence surrounding HIV prevalence and state stability, on prevalence rates among militaries and other uniformed services, and on the claim that armed conflict is a vector of HIV transmission.Footnote 25 This evidence presented HIV/AIDS as a threatening object and played a vital role in the process through which our understanding of this disease was reshaped leading to its securitisation and the passing of Security Council Resolution 1308 in January of 2000.Footnote 26 The emergence of novel viruses too can provide the material event and evidence allowing disease outbreaks to move further along the continuum of securitisation.Footnote 27 The result is that securitisation must now be understood not as self-referential and performative but as an argumentative processFootnote 28 in which debate and dialogue takes into consideration the evidence regarding the external reality of a situation or threat in an attempt to convince a particular audience. One of the key forms of evidence investigated in this article is that provided by scientific tools and in particular genetic technologies.
Science and securitisation
For thinkers investigating the power that scientific actors and evidence plays in the securitisation of political issues, the work of Bourdieu has been informative. For Trine Villumsen Berling, Bourdieu is valuable for his explicit focus on the role of science and expertise in the constitution of the social realm, making his thoughts important for understanding the role of science in society. Further, his focus on fields as structuring social reality and social universes can provide tools that enable us to better understand the external dimension of securitisation theory: the context in which securitisations take place.Footnote 29 The notion of the field allows us to break away from the societal view of science as ‘pure’ in that it produces technical expertise and objective ‘facts’Footnote 30 about the world in an apolitical wayFootnote 31 unconcerned with power. A view that not only disguises the political interests of those drawing from the objective authority of ‘scientific evidence’Footnote 32 but that also occludes the falsification, dissent, and controversy integral to the workings of science itself.Footnote 33 Bourdieu's explicit focus on the role of agency and strategic manoeuvring also connects well with the image of the securitising actor within this approach and makes important insights into how agents strive to become successful in securitisation attempts.Footnote 34 In this way, Bourdieu gives us insight into the role that scientific actors and evidence plays in both the external and internal mechanisms through which securitisation occurs.Footnote 35
One of the key external factors identified in the role of science in securitisation processes concerns the way that science objectifies its object of study. For Bourdieu, the veil of scientific objectivity is a social product of its field.Footnote 36 This generates a practice of objectification by scientific researchers, which leads to the systematic categorisation and rationalisation of human practice and solid conclusions regarding the natural world.Footnote 37 Such practical activity as an object of observation, analysis, and representationFootnote 38 risks destroying its object or creating pure artefacts whenever it is applied without critical reflection.Footnote 39 As Berling notes, the scientist consecrates social reality with a scientific status, making it very difficult to change while also potentially prescribing action that exercises a specific kind of symbolic violence.Footnote 40 The consequence of objectivation – the power to define and categorise – shapes political discussion and can close down controversy. This adds a significant contextual dimension to the political process in that science can exert a considerable degree of influence on what is being said and what is not.Footnote 41 It has particular power in (co)determining the setting and the issues deemed legitimate and ‘true’ as objects of security.Footnote 42 As we will see, genetic technologies demonstrate a particular power of objectivation in that they literally make intelligible the nature of viruses that would otherwise remain unknowable.
One of the key internal factors identified in the role of science in securitisation processes concerns the mobilisation of scientific facts to suit particular political agendas. Facts, scientific models, and data can all be mobilised strategically by agents in political struggles in their efforts to secure for themselves the power to impose the legitimate version of the social world and its divisions.Footnote 43 These efforts also close off debate and create doxic or taken for granted practices that also objectivise the understanding of a threat or situation. Framed in technical terms, the knowledge about this relation can only be challenged by those with scientific capital using similar vocabulary or technological techniques.Footnote 44 For Berling, the value ascribed to scientific facts should be kept in mind when analysing securitisation attempts and this constitutes a key internal mechanism of science in relation to securitisation.Footnote 45
Importantly though, there is no causal mechanism or direct relationship between the objectivation of scientific objects, the mobilisation of scientific ‘facts’ and successful securitisation. These two elements do not guarantee success but are certainly important factors to be reckoned with.Footnote 46 Indeed, as this article argues, scientific evidence provided by genetic technologies is now a necessary part of the process through which infectious disease outbreaks are securitised by the WHO in the declaration of PHEIC. Clearly, these technologies alone are not sufficient to determine the securitisation of infectious disease outbreaks, yet we must understand the vital role they now play. As we will see now, the WHO's response to the SARS outbreak of 2003 would give it new powers to categorise the outbreaks of particular viruses as potential PHEIC.
The IHRs, WHO, and the securitisation of infectious disease
As part of the revised 2005 IHRs the WHO gained new powers to securitise infectious disease outbreaks via the declaration of a PHEIC. These new powers would allow it to declare a public health emergency in relation to a number of events, including in direct response to the emergence of novel pathogens and the re-emergence of known ones. These events are collected, shared, and made intelligible via the national surveillance systems supported by the WHO. The WHO's surveillance capabilities have developed over time in relation to the IHRs and other international initiatives, including the Pandemic Influenza Preparedness (PIP) Framework. As many commentators have noted, the WHO's exceptional efforts in dealing with the SARS outbreak of 2003 set the ground for the revision of IHRs that followed.Footnote 47
The revised IHRs were adopted by the World Health Assembly (WHA), the policymaking arm of the WHO, in May of 2005.Footnote 48 Reflecting the active role the WHO had played in the SARS outbreak a few years earlier, the new IHRs introduced the notion of the PHEIC, giving this organisation new powers to categorise the spread of disease as an international emergency. Via the declaration of a PHEIC, the WHO could also now issue non-binding temporary recommendations to States Parties concerning how they should respond to such emergencies and routine public health risks.Footnote 49
A PHEIC has been defined as an extraordinary event that constitutes a public health risk to other states through the international spread of disease and that may require a coordinated international response.Footnote 50 Its purpose is to focus international attention on acute public health risks that require the coordinated mobilisation of extraordinary resources by the international community to prevent and respond to disease outbreaks.Footnote 51 The declaration of a PHEIC brings into play extraordinary measures, including increased disease surveillance, restrictions on international travel and trade, such as border closures and quarantine, the invocation of national influenza pandemic preparedness plans, and the emergency use of novel vaccines or therapeutics.Footnote 52 Such trade and tourism restrictions can cause significant harm to a country's economy. This declaration has also been associated with increased levels of urgency and support from the international community, including financial resources, enhanced diplomatic efforts and security.Footnote 53
The WHO's failure to consistently invoke a PHEIC has led to criticisms asserting that the implementation process appears ‘more political than technical’.Footnote 54 It's decision-making power in this regard is so significant, then, as the failure to declare a PHEIC sends a message to the international community that the situation is not an international emergency and so does not require a surge response and the mobilisation of global resources and communities.Footnote 55
In a dramatic shift away from the previous regulations, a PHEIC and its recommendations can now be declared without obtaining the permission of State Parties potentially harmed by such actions.Footnote 56 The determination and declaration of the existence of a PHEIC represented a new power to securitise infectious disease outbreaks. As Tine Hanrieder and Christian Kreuder-Sonnen note, this is delegated to the WHO Director-General, who ‘shall make the final determination on this matter’.Footnote 57 This decision is made in coordination with the views of an Emergency Committee whose members are selected by the Director-General from the IHRs expert roster.Footnote 58 However, recent investigations have shown that this is not always the procedure.Footnote 59 As set out in the IHRs, the discovery of human influenza caused by a new subtype or unknown virus, the re-emergence of the Ebolavirus and any event of potential international public health concern, including those of unknown causes or sources such as the emergence of the SARS-CoV-2 virus responsible for COVID-19, may alone represent the basis and impetus for the declaration of a PHEIC.Footnote 60
As we shall see, the declaration of PHEICs in response to the 2009 H1N1, 2014–16 Ebola, and ongoing COVID-19 outbreak were underpinned by surveillance networks and molecular technologies that made visible and intelligible the nature and spread of these viruses, respectively, making possible their understanding as objects to be securitised. Crucially, these technologies made the inherent characteristics or natureFootnote 61 of the threat in question visible and intelligible to the audience charged with assessing the severity of an outbreak and declaring a PHEIC.
Recognising the essential reliance that any WHO declaration has upon disease surveillance networks and the sharing of information by its member states with it, the revised IHRs also set out a range of new capabilities for the organisation and responsibilities for member states in relation to surveillance. The dramatic expansion of the scope of the IHRs included the creation of obligations on State Parties to develop minimum core surveillance and response capacities.Footnote 62 As we will see now, one of the core components of any surveillance mechanism is its ability to make the objects of concern visible and intelligible in relation to their external environment.
Global disease surveillance and molecular technologies
Surveillance and visualisation
Surveillance, facilitated by technologies such as communication networks, has been analysed as being inherently tied to the creation of regimes of in/visibility.Footnote 63 These regimes are vital to wider political and security projects focused on identifying, managing and classifying people into groups in relation to levels of threat.Footnote 64 The surveillance of disease at the level of the population too is tied to technologies such as statistical analysis that make visible its prevalence across different age groups.Footnote 65 New technologies in the molecular sciences and in the form of algorithms have intensified the search to make visible and intelligible the occurrence of disease and its classification into new objects of knowledge.
With regard to algorithms, syndromic surveillance systems have emerged as routine rapid detection devices. Syndromic surveillance marks a departure from more traditional and fixed forms of public health surveillance, which tended to rely upon the reporting of official scientific and statistical health information to guide responses to emergent health emergencies.Footnote 66 The flows of data from hospital emergency departments, hospital admissions, sales of medicines from pharmacies, telephone calls to health advice providers, levels of absenteeism at school and/or workplaces, etc. are continuously monitored and captured in tools such as HealthMap to gather early indications of a new disease outbreak or bioterrorist attack.Footnote 67
Molecular and genetic technologies have also made it possible for us to visualise and intervene in life at the molecular level.Footnote 68 We can now analyse viruses and bacteria in terms of their genetic sequences that reveal their nature or inherent characteristics. The data of these sequences, particularly that of viruses and other pathogens of concern can be used to reconstruct any virus for which an accurate genetic sequence exists.Footnote 69 These sequences can also be rapidly shared via the Internet. Organisations such as the Global Initiative on Sharing All Influenza Data (GISAID) and EpiFlu™, form repositories of high-quality influenza genetic sequence data that can be shared between scientists at the click of a mouse in efforts to create new medicines.Footnote 70
For some commentators such as Zygmunt Bauman and David Lyon the increasing speed and flexibility with which information can be gathered and shared between networks represents a fundamental shift from previous notions regarding the workings of surveillance. One conception, captured in Bentham's panopticon, is a modern form of surveillance that worked according to fixed understandings of time and space for both inmates and surveillants.Footnote 71 Supported by transnational and instantaneous communication networks as revealed by Edward Snowden, surveillance now takes on a liquid form in its flexibility, collapsing traditional notions of time, distance, and space. It is now mobile and all encompassing.Footnote 72 The world of fixity and enclosure has dissolved into global and local flows across networks.Footnote 73 The body along with its pathogens are reduced to data in the creation of the doppelgänger data-double.Footnote 74
In contrast to these liquid forms of disease surveillance this section will now detail the WHO surveillance networks set up to gather and share information on disease threats, particularly that posed by the influenza virus. These networks, just like those detailed above, rely upon technologies to make the pathogenic threat visible, intelligible and categorisable as an object of knowledge. Yet, they also rely upon the collection of physical samples in order to carry out their analysis and threat classification. This necessitates the creation of fixed nodes in a surveillance network that are subject to the traditional constraints of distance and that are linked in ‘real time’Footnote 75 in the collection and sharing of samples. As this section will show, genetic sequence data reveals the occurrence of a novel virus outside of known classifications and RT-PCR tests reveal the prevalence and rate of known viruses across and within a population. The visibility of the genetic constitution of molecular life has now become a necessary tool in generating evidence regarding the nature and spread of an outbreak that can be mobilised in the declaration of a PHEIC and the securitisation of a disease threat.
The WHO's pandemic influenza surveillance network
The WHO's ability to determine the severity of a disease outbreak for the international community and securitise it via the declaration of a PHEIC is directly linked to the surveillance networks that feed into and share information with it. The largest network created by the WHO is that focused on the early detection of influenza. At the core of this network is the WHO's Global Influenza Programme (GIP), initiated in 1947. One of the most important goals of this programme is the monitoring and tracking of influenza outbreaks. To facilitate this the GIP provides Member States with strategic guidance, technical support, and the coordination of activities to help make their health systems better prepared against seasonal and pandemic influenza threats. This section will outline the essential elements in the WHO's influenza surveillance network along with the role that genetic sequence data plays within it in the generation of scientific evidence that identifies viruses with pandemic potential and contributes to the development of RT-PCR tests.
In order to monitor and track influenza outbreaks, since 1952, global influenza surveillance has been conducted through the WHO's Global Influenza Surveillance and Response System (GISRS). This system, one of the partners in the Global Outbreak Alert and Response Network (GOARN) and formerly known as the Global Influenza Surveillance Network up until 2011, is a global alert mechanism focused on the emergence of influenza viruses with important features, including those that represent new seasonal variants and those with pandemic potential.Footnote 76 It is set up to provide early warning of genetic changes in influenza viruses circulating in the global population, to help mitigate the consequences of potential pandemics and maintain the efficacy of seasonal influenza vaccines.Footnote 77
One of the ways in which GISRS acts as an early warning mechanism is by identifying and tracking the genetic changes that are occurring in the genomes of influenza viruses that can make them more virulent and transmissible in human populations. This is done through a network of laboratories that collect and share information on viruses circulating across the globe. The GISRS network is made up of WHO designated National Influenza Centres (NICs), WHO Collaborating Centres on influenza (WHO CCs), H5 Reference laboratories (H5RLs), and Essential Regulatory Laboratories (ERLs) that are coordinated by the GIP.
As of 2018, GISRS comprised of 152 institutions, including seven WHO CCs, four ERLs, 13 H5RLs, and 144 NICs in 114 countries, with about 60 per cent of WHO member states participating in global influenza surveillance.Footnote 78 These GISRS laboratories conduct research on influenza viruses received for public health surveillance purposes and also submit and share genetic sequence data to GISAID, Genbank and other similar public databases.Footnote 79 ERLs exist in the US, UK, Japan, and Australia. They are formally associated with national regulatory agencies and have a critical role in developing, regulating, and standardising influenza vaccines for H5N1 and other influenza viruses that have pandemic potential.Footnote 80
The vast majority of viruses shared through GISRS are those that cause seasonal influenza outbreaks, with 28,000 of these shared annually with WHO CCs.Footnote 81 As viruses mutate, seasonal vaccines must be updated. This means that the bulk of GISRS's work is focused on assessing the threat that any new virus may pose. This activity necessitates seasonal risk assessment, virus characterisation, recommendations for seasonal vaccines, and the development of candidate vaccine viruses for use in these vaccines. This work is of critical importance to the effective and robust production of seasonal influenza vaccines. It is also essential to pandemic preparedness, as the same facilities will be used to manufacture any vaccine developed to combat viruses with pandemic potential.Footnote 82
The network of WHO laboratories plays a vital role in the analysis of the changes that are occurring to the genetic makeup of viruses circulating the globe. The year-round surveillance of seasonal influenza by the NICs provides the bedrock of the global virological surveillance system and its ability to respond to a pandemic.Footnote 83 Virological surveillance represents the ongoing and systematic collection and analysis of viruses in order to monitor their genetic characteristics.Footnote 84
This system begins with NICs when they receive physical clinical specimens collected from patients with influenza-like illness or severe acute respiratory infections and perform initial identification for the presence of influenza virus and attempt virus isolation.Footnote 85 In the identification of relevant influenza viruses, NICs perform virus culture and genetic characterisation by sequence analysis.Footnote 86 Next generation genetic sequencing is used by NICs primarily for virological surveillance, but it may also be used for research or outbreak investigationsFootnote 87 as was the case with SARS-CoV-2. NICs that lack access to appropriate biocontainment facilities or relevant experience of working with highly pathogenic avian influenza viruses may be unable to isolate viruses, so increasing the need to rapidly share physical samples.Footnote 88
Of particular concern to this network are viruses that are categorised as un-subtypeable and associated with human infection.Footnote 89 NICs select and share physical samples of these types of viruses with the seven WHO CCs that exist in Memphis, Koltosov, Atlanta, Beijing, London, Melbourne, and Tokyo and that then carry out detailed antigenic, genetic, and biological characterisation.Footnote 90 This analysis supports the determination of a number of factors related to public health risk assessment and risk management. This includes assessing and monitoring viral evolution and antiviral drug susceptibility and updating protocols for global virus detection.Footnote 91 The collection and analysis of the genetic sequence data of circulating viruses is essential then to the general global health security architecture dedicated to influenza pandemic preparedness and the identification of viruses that may pose a pandemic threat.
Viruses with pandemic potential
Demonstrating the objectivating power of science and as set out in the 2005 IHRs, the emergence of human influenza caused by a new or unknown subtype of virus, termed un-subtypeable, can form the basis of the declaration of a PHEIC.Footnote 92 These unclassifiable viruses are also categorised as viruses with pandemic potential. The random emergence of novel influenza viruses results from the process through which they replicate. One unfortunate characteristic of the influenza virus is its inability to accurately reproduce its genetic code when it replicates. As DNA replicates inside human cells, it is accompanied by a proofreading activity that assists this process by removing incorrectly incorporated nucleotides.Footnote 93 Nucleotides, also known as nucleotide bases, make up genetic sequences in DNA and RNA. In DNA they are represented by adenine, cytosine, guanine, and thymine with uracil taking the place of thymine in RNA. The RNA-based influenza virus lacks such a proofreading process and this results in the accumulation of point mutations during replication that lead to changes in the sequence of nucleotides and the reassortment and mutation of genes that in turn produce different proteins.
Some of the most important genes in the molecular surveillance and assessment of the pandemic potential of influenza viruses are those that determine the structure and function of the haemagglutinin (HA) and neuraminidase (NA) surface proteins. These proteins are responsible for viral entry into human cells and their release from the surface of human cells, respectively. The mutations that occur during viral replication and the changes to the sequence of nucleotides are so significant as they contain the genetic information that determines the physical biological characteristics and infectivity of a virus, demonstrated in the structure of the HA and NA surface proteins.Footnote 94
When a virus replicates using the genetic machinery of its host it not only shares its genetic material with the host, but host DNA is also incorporated into the viral genome.Footnote 95 In this way, as viruses spread, they carry this material with them, transferring DNA and RNA from one organism to another. The mutations and reassortments that result from this exchange lead to changes in the amino acids in the antigenic or infective portions of the viral HA and NA surface glycoproteins that may give selective advantages to a strain by allowing it to evade pre-existing immunity and host immune responses.Footnote 96 Subtle changes and genetic mutations are termed antigenic ‘drift’, with more substantial ones given the moniker antigenic ‘shift’. The former give rise to novel seasonal variants of the influenza virus while the latter generate potentially pandemic forms.
Surveillance of the genetic changes to influenza viruses is so important as pandemics often occur when an influenza virus of a new subtype to which most humans have little or no existing immunity ‘shifts’ to acquire the ability to cause sustained human-to-human transmission leading to global community-wide outbreaks.Footnote 97 Such a virus is not only able to evade pre-existing immunity and our pharmaceutical defences but also transmit efficiently between humans. This potential was realised with the emergence of the H1N1 influenza pandemic virus in 2009. The H5N1 and H7N9 viruses have also evolved the ability to move from animals to humans but luckily have not yet been found to spread easily from human to human.Footnote 98 As a result, the GISRS global system of monitoring and surveillance detailed above has been set up to identify, visualise, and assess the specific molecular characteristics of influenza viruses in order to determine those that may have the potential to cause a global pandemic. In other words, to categorise, objectify, and determine the nature of the threat.
As part of this system, the WHO has created global pandemic influenza virus risk assessments to inform decision-making for influenza viruses with pandemic potential.Footnote 99 A virus with pandemic potential is defined as one that ‘must, at the least, have a haemagglutinin gene and potentially also other genes that are distinct from those in seasonal influenza viruses so as to indicate that the virus has potential to spread within human populations’.Footnote 100 This includes viruses isolated from animals that have spread from animal reservoirs to humans and caused zoonotic infections, such as avian influenza H5N6 and the swine-origin H3N2 virus.Footnote 101 It also includes viruses that previously circulated in humans but no longer do so, such as the H2N2 virus.Footnote 102 A novel virus with distinctive genes representative of a new subtype combined with the ability to spread effectively in humans represent key red flags in the determination of whether this scientific object constitutes a PHEIC and should be securitised.
Genetic sequence data and RT-PCR tests
Sequence data is not only used to determine the danger a virus represents, but it is also used to design primers for surveillance and diagnostic tools such as RT-PCR tests that can tell if someone is infected with a particular virus and thus make measurable and visible infection rates across a population.Footnote 103 Fast, accurate, and comprehensive diagnostic tools such as this are central to the surveillance of emerging and re-emerging viruses, outbreak management, as well as for early antiviral treatment, prophylaxis, and infection control.Footnote 104
This technology detects parts of the genome and particular genes of the virus in question.Footnote 105 Our understanding of the full genome sequence of a virus is therefore important in the development of RT-PCR tests and the designing of PCR primers that determine the region of DNA to be detected and amplified.Footnote 106 The most frequently implemented RT-PCR diagnostic tests for the Zaire ebolavirus responsible for the 2014–16 outbreak targeted conserved (constant) domains within genes for structural elements of this virus including the glycoprotein that is involved in the infection of cells and spread of the disease in the body.Footnote 107 Tests that recognise these genes also form part of the confirmatory strategy for US cases and for samples referred to the US Centers for Disease Control (CDC) as a WHO CC for Viral Haemorrhagic Fevers.Footnote 108
RT-PCR capitalises on the function of one enzyme – DNA polymerase – to add nucleotides to a single strand of DNA. This enzyme is normally used to facilitate cell division, as when a cell divides the DNA must be duplicated. In this process the two-stranded DNA helix will separate and the DNA polymerase will add the relevant nucleotides to each single strand in the creation of a new double-stranded helix and a duplicate of the cell's DNA. As the Ebola virus has a genome that consists of RNA, the RT-PCR tests must create a complementary DNA strand from an RNA template, a process termed reverse transcription using the enzyme reverse transcriptase.Footnote 109
Once the DNA strand has been created, the polymerase enzyme then amplifies a specific part of this strand (such as the conserved domains) creating many copies, in a process known as polymerase chain reaction, which can serve as a clear and visible identifier of infection. This method of analysis is not, however, fool proof as any errors in the reverse transcription process will also be amplified by the DNA polymerase enzyme.Footnote 110
As we will see in the next three sections, this diagnostic test and genomic analysis played essential roles in the WHO's declarations of PHEIC in response to the H1N1, Ebola, and SARS-CoV-2 outbreaks. These technologies categorised and objectivised the virus of concern making either its nature or spread visible and intelligible so creating evidence of a threatening object that could be utilised by the WHO in its securitisation of these outbreaks via the declaration of a PHEIC. In the analysis of these cases I draw from publicly available reports to demonstrate the process through which the nature and spread of these viruses became understood scientifically and then securitised.
Genome sequence data and the securitisation of H1N1
On the 25 April 2009, in response to the global spread of the H1N1 ‘swine flu’ virus, the WHO declared a PHEIC, recognising that the situation represented an extraordinary event requiring immediate emergency actions on an international scale.Footnote 111 On the 11 June 2009, after thirty thousand cases had been confirmed across 74 countries, a global pandemic was declared, the first of the twenty-first century.Footnote 112 On the 24 April 2009, the full genome of this newly identified influenza virus was sequenced by the US WHO CC in Atlanta and was subsequently made publicly available on the GISAID sequence database.Footnote 113 Studies quickly made visible the nature of the threat that manifested in the ‘unique genome constellation’Footnote 114 of the virus that was genetically ‘untypable’Footnote 115 and unclassifiable. As detailed above, human influenza caused by a new and unknown subtype of virus is a key factor in the IHRs decision instrument, guiding the assessment and notification of incidents that may constitute an exceptional event and PHEIC and that should be communicated to the WHO by affected countries.Footnote 116
Viruses that are untypable or ‘un-subtypable’ cannot be matched to the catalogue of known viruses or subtypes. Influenza A viruses are divided into subtypes based on the 18 different haemagglutinin and 11 different neuraminidase surface proteins found in the natural world to date.Footnote 117 As detailed above, ‘un-subtypable’ viruses often have this characteristic after they have undergone substantial antigenic or genetic changes. Following detailed genetic analysis, it was soon revealed that this H1N1 virus contained the genetic components of three distinct organisms: humans, pigs, and birds.Footnote 118 Pigs have been identified as the ideal mixing vessels for the generation of new viruses as they are not only susceptible to infection by swine viruses but also bird and human influenza viruses too.Footnote 119
As word spread among the international community that a novel virus was now circulating widely, the WHO began to assemble an Emergency Committee from the IHR Roster of Experts.Footnote 120 Once assembled, the Committee focused on collecting more detailed information on the epidemiology, virology, and clinical characteristics of this new virus before advising the Director-General on the announcement of the PHEIC. In line with the IHRs, Committee members advised the Director-General on the announcement of the PHEIC that was carried through on the 25 April.Footnote 121 As a result, over the next few days and as the disease spread, the Director-General recommended that all countries intensify surveillance for unusual outbreaks of influenza-like illness and severe pneumonia. As the virus had already spread widely by this time, the strategy of containment and the more stringent security measures of quarantine, border closures, and restrictions on international trade and travel were rejected in favour of recommendations focused on mitigation. This was not followed by every country or region, though, with Hong Kong implementing quarantine measures and China doing the same to Mexican or Canadian nationals arriving from their home countries or already present in China.Footnote 122
Over the months leading up to the Emergency Committee's final meeting on the 10 August 2010, countries were encouraged to maintain their surveillance measures. At this time more than 214 countries and overseas territories or communities had reported laboratory confirmed cases of pandemic H1N1.Footnote 123 Based on the global situation, the Committee recognised that the spread of H1N1 seemed largely to have ‘run its course’ and would likely continue to circulate for some years to come, taking on the behaviour of a seasonal influenza virus. As a result, it was agreed that the global influenza situation no longer represented an extraordinary event requiring immediate emergency action on an international scale.Footnote 124 The Committee advised the Director-General that the PHEIC should be ended and that the temporary recommendations adopted in response should be terminated.
The failure both of the virus to mutate into a more lethal form and for widespread resistance to the antiviral oseltamivir/Tamiflu to develop, in addition to the creation of an effective and safe vaccine, created the fortunate conditions out of which a very mild pandemic was realised.Footnote 125 This was, though, an infectious disease outbreak that was securitised in coordination with scientific evidence that categorised and objectified the virus in relation to its unique and untypable nature. This scientific evidence was made visible and intelligible via the detailed sequencing of its genome. As we will see now, another molecular technology in the form of RT-PCR tests would also play an essential role in providing evidence for the securitisation of an outbreak of Ebola a mere five years later.
RT-PCR tests and the securitisation of Ebola
On the 8 August 2014, the WHO declared the Ebola virus disease (EVD) outbreak in West Africa a PHEIC, stressing the need for international attention and collaboration to control and mitigate its effects.Footnote 126 A month later on the 18 September, the UN Security Council declared that this outbreak constituted a threat to international peace and security and called on Member States to respond urgently to the crisis, and to refrain from isolating the affected countries. This outbreak primarily affected the countries of Guinea, Liberia, and Sierra Leone and would result in the most widespread occurrence of this disease in history. The virological investigation identified and categorised Ebola Zaire as the particular species and strain of Ebolavirus responsible for this outbreak.Footnote 127
Following the declaration of a PHEIC, the WHO put forward temporary recommendations emphasising the travel restriction of all EVD cases and contacts but stated that there should be no general ban on international travel or trade. All states were advised to be prepared to detect, investigate, and manage EVD cases. Unfortunately, dozens of countries implemented measures in response to this crisis that neither followed the WHO's recommendations, nor had a scientific and public health justification, such as travel bans or restrictions on persons travelling from West Africa.Footnote 128 Many countries also failed to inform the WHO when implementing these measures or justify them when asked to, signifying for David P. Fidler a further violation of the international legal obligations prescribed in the IHRs.Footnote 129 It has also been noted that the international political motivation to intervene in West Africa only arose in July 2014 after the first case of Ebola was diagnosed outside of Africa.Footnote 130
As with many other viral haemorrhagic fevers, Ebola can be difficult to diagnose, and requires laboratory diagnostics in order to confirm or rule out infection with confidence.Footnote 131 As a result, rapid and reliable laboratory testing for the diagnosis of suspected Ebola cases is essential in making the spread of this virus visible and intelligible as an object of knowledge. This information is also vital to the control of the virus via the initiation of contact tracing.Footnote 132 During this outbreak, the WHO organised laboratory response activities as part of the Emerging and Dangerous Pathogens Laboratory Network (EDPLN) and GOARN. The WHO in coordination with the EDPLN, which includes WHO CCs, set up a global laboratory database that centrally compiled data in order to understand global disease trends and guide public health interventions.Footnote 133
From March 2014 onward, WHO EDPLN, together with GOARN and partners, deployed 32 laboratories into the three most affected countries and Nigeria to provide safe and high-quality laboratory diagnostic services.Footnote 134 Their efforts were also focused on providing clinical care, the identification of new cases and the monitoring of survivors. They also ensured that all districts, counties, and prefectures in the affected countries had access to laboratory testing capacity within 24 hours.Footnote 135 The EDPLN network was instrumental in providing a fixed platform for the laboratory analysis of RT-PCR tests to not only confirm cases of EVD but to also direct patients to treatment centres. Confirmed cases of the disease using this test were also used in contact tracing efforts.Footnote 136 The information provided proved essential in making visible and intelligible the reality of the regional epidemiological situation, including the increased spread and growth in cases.
In April 2015, the database was made up of 86,154 samples taken from approximately 1,600 unique spreadsheets from 32 laboratories located in the three countries.Footnote 137 The number of laboratories involved would grow to 47 by the end of the outbreak and 256,343 specimens would eventually be tested from March 2014 through to August 2016.Footnote 138 At the core of this data collation was the collection and analysis of specimens from patients presenting at hospitals, treatment centres, and clinics with symptoms of EVD. All specimens were transported to the laboratories for subsequent real-time qualitative RT-PCR testing.Footnote 139
As testing ramped up from March 2014 onward a positivity rate of around 50 per cent was revealed from June up until the declaration of the PHEIC by the WHO in early August.Footnote 140 Across the three countries the number of cases and deaths rose from 86/59 on the 25 March to 1617/886 on the 4 August,Footnote 141 a massive increase of 1780/1401 per cent respectively. The WHO Emergency Committee, following a meeting on the 6 and 7 August, unanimously decided that the conditions for a PHEIC had been met. On the 8 August, 2014, the WHO declared a PHEIC stating that this outbreak constituted an ‘extraordinary event’ and a public health risk to other States.Footnote 142 This was a result of ‘the intensive community and health facility transmission patterns’, the virulence of the virus, and the weak health systems in the countries affected.Footnote 143 The nature and spread of this disease outbreak, these transmission patterns and rates of infection across the population groups tested were made visible and intelligible via the utilisation of RT-PCR tests.
These tests made visible and intelligible the increasing spread and threat that Ebola posed in this region forming it into an object to be securitised. As a result, a call was issued for a coordinated international response to stop and reverse its international spread. The PHEIC was lifted on the 29 March 2016, following 28,616 confirmed, probable and suspected cases with 11,310 deaths.Footnote 144 As we will see now, a combination of the genetic technologies discussed so far was utilised in our understanding of the novel nature of the SARS-CoV-2 virus and its securitisation.
Genome sequence data, RT-PCR tests, and the securitisation of COVID-19
On the 30 January 2020, following the recommendations of the Emergency Committee, the WHO Director-General declared that the outbreak of COVID-19 constituted a PHEIC.Footnote 145 This declaration followed the discovery and objectivation of the threat of this novel virus using a combination of PCR, RT-PCR tests, and genome sequencing and its rapid spread across the globe and serious public health impact.Footnote 146 In response, countries around the world were advised to prepare for containment, including active surveillance, early detection, isolation and case management, contact tracing, and the prevention of onward spread of infection.Footnote 147
By the end of January 2020, the virus had travelled from China to 18 other countries with only seven of these cases having no history of travel in China. Human-to-human transmission was also recorded in three countries outside China. Following this, the virus proceeded to move across the globe leaving few places unaffected. In response, countries around the world implemented a range of restrictive travel and trade measures, particularly against China, acting in violation of their obligations under the IHRs and the advice of the WHO at the time.Footnote 148 As of the 16 December 2022, there have been 647,972,911 confirmed cases of COVID-19, resulting in 6,642,832 deaths, reported to the WHO.Footnote 149
The novel nature of this coronavirus was determined using a combination of PCR, RT-PCR tests, and genome sequencing technology. PCR and RT-PCR tests analysed samples for the presence of 22 different pathogens, 18 viruses, and 4 bacteria to eliminate the presence of known microbes.Footnote 150 In combination with these tests, high-throughput genetic sequencingFootnote 151 and metagenomics next-generation sequencingFootnote 152 were utilised to objectify and make visible the whole genome of the virus, discover microbial sequences not identifiable by the PCR and RT-PCR tests and make intelligible the novel characteristics of this pathogen and the threat that it posed to the global population.
This novel coronavirusFootnote 153 was first sequenced by the National Institute of Viral Disease Control and Prevention,Footnote 154 part of the Chinese WHO CC in Beijing, identified above. The sharing of the complete genetic sequence of this virus online in early January 2020 was fundamental to its characterisation, enabling the rapid development of diagnostics and the development of therapies and vaccines.Footnote 155 Complete sequences uploaded to GISAID supported the phylogenetic or evolutionary analysis of the virus that would reveal its relationship with different organisms. While this virus shared around 86 per cent of its genetic material with SARS from 2003, it poses much more of a public health threat because of its higher reproductive rate and high proportion of asymptomatic infections that amplify the outbreak through silent spread.Footnote 156
In response, a range of surveillance efforts around the world were sparked to develop RT-PCR tests that could confirm suspected cases of COVID-19. Consensus or conserved regions of the virus's genetic code were used to design RT-PCR testsFootnote 157 and the primers used in the designation of these tests were shared with the WHO to aid surveillance and detection activities in China and around the world. The WHO quickly developed guidance for countries on how to implement surveillance systems that could not only monitor the spread of the virus within populations but also measure the changing characteristics of the viral genome itself as has been revealed with the identification of novel variants to date labelled Alpha, Beta, Gamma, Delta, and Omicron.Footnote 158 This surveillance would utilise both RT-PCR and genomic sequencing technologies.
In order to facilitate the range of sequencing needed to maintain surveillance the WHO set up a COVID-19 Reference Laboratory Network to provide confirmatory testing.Footnote 159 In coordination with this network, the WHO also set up the SARS-CoV-2 Evolution Working Group focused on providing timely information on the identification and evaluation of potentially relevant mutations, as well as advice for risk mitigation.Footnote 160 The WHO has also leveraged and utilised NICs and the range of other laboratories within GISRS to facilitate genomic surveillance of SARS-CoV-2 and monitor genetic variants.Footnote 161
As of the 16 of December 2022, the WHO Director-General determined that the COVID-19 pandemic continues to constitute a PHEIC.Footnote 162
Conclusion
This article has investigated the WHO's declaration of a PHEIC and the securitisation of three infectious disease outbreaks in the form of H1N1, Ebola, and COVID-19. It has argued that the securitisation of these outbreaks was dependent upon global surveillance networks that utilised genetic technologies to visualise and categorise the molecular characteristics and spread of the pathogen in question. These instances of securitisation give us new insight into the role that visual evidence in the form of genetic data on pathogens plays in this process. In the case of H1N1 the unique genetic sequence data of the virus was an important driving factor in the WHO's decision to declare a PHEIC. In the case of Ebola, too, the widespread re-emergence of this well-known virus within the West African population, made intelligible via the use of RT-PCR tests, was a vital factor in the declaration of the PHEIC. The case of COVID-19 also revealed the key role that genomic sequencing and RT-PCR tests played in revealing the unique nature of the SARS-CoV-2 virus and its spread around the world in the declaration of the PHEIC.
Drawing from the literature focused on the role of science in securitisation efforts this article identified two key dynamics through which genetic technologies were able to play such a vital role in the declaration of PHEIC in these cases. Firstly, in relation to H1N1, Ebola and SARS-CoV-2, these technologies revealed the novel molecular characteristics and prevalence of these viruses within populations that literally created them as objects of knowledge. This process of objectification led to their categorisation and securitisation in terms of the threat that they posed to the health of the international community. Secondly, the evidence in all three cases was mobilised by the WHO Director-General and the Emergency Committee to support their securitisation agenda and the declaration of a PHEIC. In combination with the surveillance networks that facilitate them, scientific evidence provided by genetic technologies is now playing a necessary and essential role in the process through which the WHO securitises infectious disease outbreaks via the declaration of PHEIC. As a result, the securitisation of infectious disease outbreaks is now reliant upon the evidence made intelligible by genetic technologies.
Of course, the securitisation of infectious disease is still subject to political dynamics and prejudices and the evidence provided by genetic technologies on the nature and spread of infectious pathogens alone is not sufficient in determining the declaration of a PHEIC. This case though demonstrates the extremely influential and now necessary role that evidence on the genetic data of pathogens plays in this process. To date, this element has been overlooked by thinkers working in this area. Commentators have noted that the process of securitising health threats is frequently shaped by non-medical considerationsFootnote 163 and that relevant evidence cannot, in itself, account for the belief of a community in a security phenomenon.Footnote 164 While this article has argued that indeed, genetic technologies alone cannot generate the securitisation of infectious disease outbreaks, we must now come to understand their increasing power to make intelligible the nature of disease causing pathogens and the way that these understandings influence our political and security practices. If as Alison Howell notes, health and medicine has always been imbricated within security and military efforts,Footnote 165 we are now seeing the ways in which particular genetic technologies now play a necessary role in the securitisation of infectious disease outbreaks.
One wider implication of this contribution relates to the way in which the analysis of the role of genetic technologies can give us insight into the securitisation of infectious disease outbreaks around the world and outside the bounds of the states of the Global North. As Claire Wilkinson has argued, securitisation theory universalises a political system that predominantly reflects European and North American understandings of society and the state in terms of political continuity, stability, and cohesion that, in contrast, is not present in many developing countries, if indeed it is present in Western countries at all.Footnote 166 The result is a civilisationist dynamic in which Western societies and states are positioned as more ‘advanced’ than their underdeveloped others.Footnote 167
One of the effects of the recent COVID-19 pandemic has been the increasingly widespread use of genomic sequencing to guide public health responses in near-real time. For the WHO this has represented nothing less than a revolution in viral genomic investigations.Footnote 168 While there are very severe and widespread inequalities that surround and structure the architecture of global health security, not least in the economic, racial, and epistemic realms, Low and Middle Income Countries are in the process of developing their own biomedical capabilities.Footnote 169 These capabilities will build on and extend the increasingly global landscape of genomic surveillance that has emerged through efforts to combat the SARS-CoV-2 virus and its variants.Footnote 170 The result is an opening up of the horizon through which we can understand the ways in which infectious disease outbreaks are securitised around the world in the development of nuanced conclusions that can engage more sensitively with local conditions.
Acknowledgements
I am grateful to members of the Global Health Studies Section of the International Studies Association, the Global Health Working Group of the British International Studies Association, and the Global Health Section of the European International Studies Association for feedback on the presentation of these ideas at various points over the last few years. I am also grateful to Anna Stavrianakis for her advice and the reviewers and editors of the European Journal of International Security for their feedback and engagement with this article.
Funding
This research was supported by a Leverhulme Trust Early Career Fellowship (2020–3).
Declaration of Conflicting Interest
The author declares that there is no conflict of interest.
Christopher Long is a Leverhulme Early Career Fellow (2020–3) and Researcher at the Centre for Global Health Policy in the Department of International Relations at the University of Sussex, UK. His research is focused on the political dynamics at the intersections of security, biology, and biotechnology. He is the author of The Molecularisation of Security: Medical Countermeasures, Stockpiling and the Governance of Biological Threats published as part of the Routledge New Security Studies Series.
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