Since the United Nations and the U.S. National Intelligence Estimate first declared infectious disease (ID) a security threat in the early 2000s (Elbe, Reference Elbe2006), the political science literature, especially in international relations, has focused on the nexus between ID and politics. The relevant academic scholarship seems to come in waves, however, generally following significant epidemics and pandemics. For instance, studies proliferated with the study of the HIV/AIDS pandemic. Heinecken (Reference Heinecken2001) investigated the relationship between global HIV/AIDS infection rates among military personnel and the implications this posed for national and international security. In this vein, Ostergard (Reference Ostergard2002) studied how HIV/AIDS was a security threat through multiple dimensions for African nation-states. Elbe (Reference Elbe2002) looked at how HIV/AIDS influenced components of armed conflicts in Africa, including the combatants, how the conflicts were waged, and the social significance. The scholar found that HIV/AIDS elevated the social cost of armed conflict, especially in Africa (Elbe, Reference Elbe2002, p. 160). Singer (Reference Singer2002) explained how HIV/AIDS threatened to heighten the risks of war and multiply its impact.
These are just a few details of several landmark studies connecting HIV/AIDS and political science, but other themes, such as HIV/AIDS and international cooperation (Boone & Batsell, Reference Boone and Batsell2001; Elbe, Reference Elbe2006), HIV/AIDS and international peacekeeping (Bratt, Reference Bratt2002; Tripodi & Patel, Reference Tripodi and Patel2002), and HIV/AIDS as a human security threat (Fourie & Schönteich, Reference Fourie and Schönteich2001), have all brought attention to this relationship. The literature between ID and political science/security studies continued amid the SARS outbreak of 2002 and has persisted since then, continuing through the COVID-19 pandemic (see, e.g., Curley & Thomas, Reference Curley and Thomas2004; Davies, Reference Davies2008; Prescott, Reference Prescott2003; Price-Smith, Reference Price-Smith2008).
Perhaps no subfield has been more active at the crossroads of ID and political science than security studies (Enemark, Reference Enemark2009; Evans, Reference Evans2010), and within that genre, critical security studies and securitization (Davies, Reference Davies2008; Elbe, Reference Elbe2011). However, research to improve preparation for and prevention of ID through epidemic methodologies has been less common even within security studies. Specifically, aspects of what can be called public health intelligence, or epidemic intelligence, has been understudied. In a seminal first piece of epidemic intelligence, Carey and Maxfield (Reference Carey and Maxfield1972) described Project IMPACT, whose purpose was to investigate and forecast an outbreak of meningitis in China in 1966–1967.Footnote 1 The authors noted that “the concept of this project—forecasting disease problems and epidemics, and the assessment of their effects on military and civilian activities—had hardly scratched the surface of implementations” (Carey & Maxfield Reference Carey and Maxfield1972, p. 71). More recently, an entire issue of the journal Intelligence and National Security focused on health security intelligence. Particularly relevant to this letter are articles covering Ebola as a health intelligence failure (Ostergard, Reference Ostergard2020), human intelligence during epidemics (Bernard & Sullivan, Reference Bernard and Sullivan2020), the rapid validation of disease outbreak intelligence (Hatfill, Reference Hatfill2020), and the improvement of health intelligence among the countries that make up the Five Eyes intelligence alliance (Australia, Canada, New Zealand, United Kingdom, and United States) (Walsh, Reference Walsh2020).
The COVID-19 pandemic has also stimulated more scholarship in health intelligence surveillance (Greitens, Reference Greitens2020), including new spaces and sources for health intelligence (Lentzos et al., Reference Lentzos, Goodman and Wilson2020) and for epidemic intelligence fusion centers (Albert et al., Reference Albert, Baez, Hunter, Heslen and Rutland2023). The COVID-19 pandemic seems to have solidified a permanent research agenda connecting political science and ID as a “niche”Footnote 2 subfield. International relations scholars have paid more attention to this connection as well, as demonstrated in International Organization’s 2020 online supplement, particularly Drezner’s (Reference Drezner2020) and Johnson’s (Reference Johnson2020) pieces, which both make sense of COVID-19 through the lens of international relations; Fazal’s (Reference Fazal2020) essay on health diplomacy is especially insightful. Although serious attention has been given to ID and political science for around three decades, more work is needed to bridge the gap between health intelligence and political science, especially given the aftermath and continuing effects of COVID-19.
The purpose of this letter is to provide a research agenda for political science by introducing readers to health intelligence. To do so, it conceptualizes critical components and concepts of health intelligence. A brief review of the literature is provided, concluding with possible future research agendas and research questions. The aim is to elaborate upon public health intelligence’s importance to national security studies, and to political science more generally. Hopefully, political scientists will read this as a call to action within this understudied but growing research agenda.
Public health intelligence and related conceptualizations
Lowenthal (Reference Lowenthal2017), a prominent scholar of intelligence studies, usefully conceptualizes intelligence as
the process by which specific types of information important to national security are requested, collected, analyzed and provided to policy makers; the products of that process; the safeguarding of these processes and this information by counterintelligence activities; and the carrying out of operations as requested by lawful authorities. (p. 10)
Information within the health domain that is critical to national security and public policy falls under the categorization of public health intelligence (PHI), but it has been siloed within public health studies, where it is often neglected by political scientists. PHI consists of “concepts, methods, practices, and apparatuses assembled to monitor and detect health events” (French & Mykhalovskiy Reference French and Mykhalovskiy2013, p. 177). French and Mykhalovskiy (Reference French and Mykhalovskiy2013) suggest that the central aim of PHI is the detection of health events as they unfold and, preferably, beforehand (p. 174). A slightly more nuanced understanding of PHI is epidemic intelligence (EI).
EI encompasses all activities related to the early identification of potential health hazards that may pose a risk to health and their verification, assessment, and investigation so that proper national and public health practices can be implemented (Paquet et al., Reference Paquet, Coulombier, Kaiser and Ciotti2006). According to Wilburn et al. (Reference Wilburn, O’Connor, Walsh and Morgan2019), the importance of EI is recognized internationally, and it is essential to protect the global commons from health hazards that cross international boundaries. A vital component of EI is health surveillance. Disease surveillance systems collect information on known risks, threats, and other health anomalies that is then used to assess these threats (Albert et al., Reference Albert, Baez, Hunter, Heslen and Rutland2023). Disease surveillance includes digital surveillance, which focuses on preemption and early warning of a broad range of public health hazards (Bengtsson et al., Reference Bengtsson, Borg and Rhinard2019, p. 121). Disease surveillance is now situated within the realm of open-source intelligence collection (OSINT) as well as social media intelligence collection (SOCMINT) (Bernard et al., Reference Bernard, Bowsher, Milner, Boyle, Patel and Sullivan2018).
EI complements more traditional disease surveillance by data mining informal and digital sources through event-based surveillance (Bengtsson et al., Reference Bengtsson, Borg and Rhinard2019, p. 120). This form of EI involves potentially threatening events that are biological, chemical, environmental, and/or unknown (Bengtsson et al., Reference Bengtsson, Borg and Rhinard2019). Medical intelligence (MEDINT) is information collected regarding a threat, usually biological, that can be used to craft policy that is applied to defeat this threat (Albert et al., Reference Albert, Baez, Hunter, Heslen and Rutland2023, p. 95). The U.S. Department of Defense (2017) defined MEDINT as follows:
The collection, evaluation, analysis and interpretation of relevant medical, bio-scientific, and environmental information which is of interest to strategic planning and to military medical planning and operations for the conservation of the fighting force and formation of assessments of foreign medical capabilities in both military and civilian sections. (p. 6)
Research related to health intelligence and disease surveillance can be traced to the early 1990s at the intersection of weapons of mass destruction (WMDs) and political science. Specifically, Barss (Reference Barss1992) investigated the use of EI frameworks to investigate allegations of WMD utilization in warfare. Further, Wheelis (Reference Wheelis1992) discussed strengthening biological weapons control through the use of epidemic surveillance systems. These are early examples of the connection between political science and health intelligence, but there is more room for collaboration and further research questions, including those related to bioweapons, biosecurity, and bioterrorism.
Public health intelligence and national security: An agenda for research
Now that concepts are briefly understood, we can turn to potential research agendas. Research opportunities for EI are wide open. The worldwide public health response to the COVID-19 pandemic (Greer et al., Reference Greer, King, Massard da Fonseca and Peralta-Santos2020), including public perceptions of government responses (Lazarus et al., Reference Lazarus, Ratzan, Palayew, Billari, Binagwaho, Kimball, Larson, Melegaro, Rabin, White and El-Mohandes2020), government shutdowns, and stay-at-home orders (Murray & Murray, Reference Murray and Murray2022; Murray & Rutland, Reference Murray and Rutland2022); vaccination challenges (Forman et al., Reference Forman, Shah, Jeurissen, Jit and Mossialos2021); vaccine diplomacy (Tatar et al., Reference Tatar, Shoorekchali, Faraji and Wilson2021); and the overall level of dis/mis/malinformation of the disease (Bachmann et al., Reference Bachmann, Lee and Dowse2020), demonstrates that more work is needed in this arena. Additionally, there is still a wide disparity within national security studies concerning the question of what poses a threat to nation-states. Although Albert, Baez, and Rutland (Reference Albert, Baez and Rutland2021) demonstrated the interconnectedness of human security, biosecurity, and national security, it seems that many mainstream theorists disagree and, despite the effects of COVID-19, still see national security solely in terms of military power and conflict.Footnote 3 Even beyond this, the field has an enormous research gap in EI. The following questions pose possible research agendas to help alleviate the gap between political science and EI. Questions ripe for research include the following: How have EI, PHI, and MEDINT been applied historically and to particular cases, and how have they been combined within the intelligence community? Additionally, what are the full processes and organizations, in the United States and globally, that work on public health issues related to EI? How do private, public, local, state, and federal entities work with the military in the EI paradigm? And, more generally, how does EI fit within the broader intelligence industry?
Consideration should also be given to the connection between disease surveillance and privacy. For instance, what is the proper relationship between EI, social media analysis, and disease prevention? Should there be more open analysis of this type, or should privacy rights be stronger during pandemics? Further, what have terrorists and other adversaries learned from the pandemic, and how could they use the lessons learned to conduct biosecurity and bioterrorist attacks? How could EI be used in this context of counterterrorism?
Concerning military norms and ethics, what are the potential concerns of military strikes against adversaries’ health infrastructure and supply logistics during warfare? How does EI, and specifically MEDINT, help us understand potential issues within this domain? Concurrently, what has the war in Ukraine taught us about this particular practice? How has the war affected Ukraine’s health sector and disease containment? How has COVID-19 affected military preparedness and thus national and international security overall?
Thinking globally, how can EI enhance, and be enhanced by, international cooperation? Can EI help extend cooperation between nation-states that typically do not play nicely with each other? Since diseases spread beyond border patrols, how might authoritarian and democratic nation-states cooperate more effectively? Can EI help bridge the divide between the Global North and the Global South? Could international law and cooperative institutions and regimes evolve into stronger entities as a result of COVID-19’s consequences? In this same line of international cooperation, how has vaccine diplomacy fared? Has COVID vaccination been a success, and what could have been done differently? Is there room within medical diplomacy for soft-power politics and influence? Did great power shift at all during this time as a result of the competitive nature of vaccine diplomacy exerted by Russia, China, and the United States, for instance?
Additionally, further research within EI and SOCMINT is needed. How has dis/misinformation about COVID-19 been spread through social media, and by which actors? What lessons learned can be applied to future policy discussion? These and many other arenas for research fall within the understudied purview of PHI and political science. Hopefully, this letter will stimulate new research to address these areas of need.
