Jeremy Youde. Australian Journal of International Affairs. Volume 72, Issue 6. December 2018.
Over the course of a generation, global health has gone from being a peripheral concern in international politics to assuming a prominent place on the global political agenda—and the United States government has played a substantial role in facilitating and promoting global health’s ascent up the political agenda in a bipartisan fashion. With the inauguration of the Trump Administration in the United States, though, the existing consensus about global health may face its most serious questioning. Trump came into office expressing scepticism about multilateralism, foreign aid, and the relevance of global health programs. These attitudes would appear to fly in the face of the underlying normative prescriptions that have supported global health over the past generation.
In this article, I argue that the securitisation of health may be a pragmatic strategy for maintaining attention and resources from the United States for global health in the Trump era. This article proceeds in four main sections. First, I briefly discuss how health gained attention on the global political agenda and its connections with securitisation. Second, I highlight the role that the United States has historically played in promoting global health and leading international efforts to address the issue. Third, I describe the reasons that the Trump Administration has called global health and health security into question. Finally, I argue that it may be possible to securitise global health so as to appeal to the Trump Administration’s policy preferences, but acknowledge that doing so brings its own complications.
The Rise of Global Health
Thirty years ago, it would be difficult to argue that global health played a role in international politics. During the Cold War, health was relegated to the realm of ‘really low politics’—issues considered so technocratic and humanitarian that they lacked any significant political content (Fidler 2005, 180). Today, though, global health has assumed a prominent place in international politics (Youde 2016). What explains this transformation? We can point to a few significant changes. First, the emergence and spread of new infectious diseases like HIV/AIDS demonstrated that humanity had not conquered the microbial threat (Brower and Chalk 2003, 7). Second, diseases once thought to be under control, such as tuberculosis, re-emerged in large numbers (Price-Smith 2001, 3). Third, diseases were becoming increasingly resistant to existing treatments (Fidler 1997). Fourth, fears about the possibility of biological weapons arose, especially in the aftermath of the collapse of the Soviet Union with reports from defectors about its clandestine biological weapons program (Osterholm and Schwartz 2000). Finally, outbreaks of plague in India in 1994 and cholera in Peru in 1991 proved how diseases could have far-reaching political, economic, and social effects that spread across borders (Price-Smith 2001, 49-75). These events helped convince the global community that health needed to be a bigger political priority and that international cooperation was necessary to address these challenges.
As global health’s position on the international political agenda began to grow in the early 1990s, institutional and structural arrangements changed. The United States National Intelligence Council produced two intelligence estimates about the effects of infectious disease on national and international security (National Intelligence Council 2000, 2002). The World Health Organization, which has a constitutional mandate to coordinate international responses to cross-border health issues, rose in prominence (Lee 2009). Existing intergovernmental organisations like the World Bank incorporated health into their programs (Clinton and Sridhar 2017, 126-129). New partnerships like UNAIDS and the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) have brought together state and non-state actors to address a variety of health issues and pioneer new funding models. Non-state actors like the Bill and Melinda Gates Foundation have become increasingly prominent. The overall result is that the global health governance system has become increasing complex and dense since the early 1990s.
This evolving notion that infectious disease threatens international society is frequently tied to the securitisation of health. Securitisation draws on the intellectual legacy of Austin (1962) and Searle (1969), and has become popularised within the discipline by the Copenhagen School of international relations (Buzan 1983). Rather than assuming that self-evident material capabilities determine the presence or absence of security, securitisation posits that such issues emerge from how actors conceptualise them. Once securitised, issues operate in a unique space where they are elevated on the policy agenda and not subject to the regular political debates (Ardau 2004). The securitisation of health thus reframes health as posing a potential existential threat to national and international security. It seeks to move health into the realm of ‘high politics,’ away from a focus on technical assistance and humanitarianism and toward concerns about bioterrorism, worries that infectious disease outbreak could destabilise societies, and the effects of ill health on a state’s material and security interests (Fidler 2003, 2005). The success or failure of securitisation does not necessarily depend on the actual threat posed by an issue. Within the global health space, the relationship between mortality and securitisation is nearly non-existent (McInnes and Rushton 2013, 116). Instead, framing a non-traditional security issue in terms of a security threat and one that poses uncertainty to international society can be part of a conscious strategy to generate greater attention and reach out to relevant policymakers (Allan 2017).
While securitisation may give health more of attention and funding, it comes with certain trade-offs. Elbe (2006) draws on Deudney’s (1990) argument about securitising environmental change and argues that the threat logic inherent within securitisation works against the policy responses that would be most useful in stopping the spread of HIV/AIDS and increases stigmatisation and discrimination. Harman (2014) argues securitisation can encourage governments to use health initiatives as covers for more offensive foreign policy decisions that make people mistrust health campaigns. Weir (2015) criticises securitisation for focusing solely on the concerns of the Global North and constructing the Global South solely as the source of disease threats (see also Aldis 2008). Rushton (2011) builds upon these concerns by positing that securitisation emphasises containment over prevention disease outbreaks. This prioritises short-term thinking and raises questions about whose security counts.
The argument is that not that global health has been completely subsumed within the securitisation framework. Rather, it is to highlight the relevance of this frame to international policymakers and how it has brought with it increased political attention. This environment—with increased attention to global health and its partial securitisation—is the one into which the Trump Administration emerged.
The United States and Global Health
The United States’ historical leadership role in global health is undeniable. It has provided both leadership and financial backing that have helped elevate the attention paid to it. That does not necessarily mean that the United States government has always engaged with global health for selfless reasons or that its interventions have been without problems, but it has helped the global community recognise health’s importance in at least five keys ways.
First, the United States played a major role in highlighting the connections between disease and security when it brought HIV/AIDS to the United Nations Security Council (UNSC). When the UNSC held a special session devoted to HIV/AIDS on 10 January 2000, it was the first time that the body had ever focused on a health issue. Under the leadership of US Vice President Al Gore in his capacity as President of the Council, UNSC delegates discussed how the rapid spread of HIV/AIDS threatened national and international security in unprecedented ways. Richard Holbrooke, the US Ambassador to the United Nations, lobbied Secretary-General Kofi Annan to hold the meeting in late 1999 after Holbrooke completed a ten-nation African tour and saw the devastation wrought in countries with high HIV prevalence rates. Annan reportedly resisted, telling Holbrooke that HIV/AIDS was not a security issue and therefore not within UNSC’s remit. Holbrooke challenged this, in part because he thought that the international community would not pay attention unless UNSC took it up (Feldbaum 2009, 149-150). He later told an interviewer,
Look at the facts; it (HIV/AIDS) is not simply a humanitarian issue. If a country loses so many of its resources in fighting a disease which takes down a third of its population, it’s going to be destabilized, so it is a security issue (PBS 2006).
In addition, Holbrooke’s diplomatic background allowed him to bring together a wide array of policymakers, scientists, and activists to help shape global discourse around the response to the disease (Chollet and Power 2011). There were also domestic political considerations at play. Gore was running for president, and he was looking to burnish his foreign policy credentials and improve his reputation with AIDS activists (David 2001, 578-579). Regardless of the motivation, the United States’ diplomatic efforts played a large role in promoting greater attention for global health issues.
Second, the United States has played a major role in large-scale international health programs. The President’s Emergency Plan for AIDS Relief (PEPFAR) brought a massive amount of funding for HIV/AIDS and helped spur increased contributions from governments and other bodies. When President George W. Bush announced PEPFAR’s creation during his State of the Union speech in 2003, he declared, ‘This nation can lead the world in sparing innocent people from a plague of nature’ (Bush 2003). This program pledged $15 billion over 5 years to address HIV/AIDS globally. At the time, it was the largest foreign aid program for health from a single country in history (Kolker 2018), and it spurred additional investments from other governments (Dybul, Piot, and Frenk 2012, 16). Since its initial creation, PEPFAR has been reauthorized and expanded and is responsible for providing more than 7.7 million people with antiretroviral drugs and more than 56 million HIV tests (Office of the United States Global AIDS Coordinator 2016). In 2009, PEPFAR became part of an even larger US government-sponsored health program, the Global Health Initiative (GHI)—a six-year, $63 billion plan to develop a comprehensive American global health strategy (Kaiser Family Foundation 2011). While PEPFAR has received criticism for its involvement of faith-based initiatives and US-based pharmaceutical companies and for not partnering with recipient governments well (Ingram 2010; Lyman and Wittels 2010), its successes demonstrated that it was indeed possible to massively scale up the supply of anti-AIDS drugs and expand the scope and scale of global health initiatives. Fidler (2018) argues that PEPFAR ‘contributed to a revolution in global health governance.’
Third, the United States has consistently been the world’s largest funder of development assistance for health (DAH). In 2017, donor states provided $37.4 billion in DAH in low- and middle-income countries. The United States alone provided $12.4 billion—one-third of the global total, even after decreasing its contribution by 10 percent from 2016 (Institute for Health Metrics and Evaluation 2018, 16, 28). While this is not the largest contribution by percentage of a country’s gross domestic product, the raw dollar amount is crucial for the operation of many global health programs. This is precisely why so many observers were worried about the potential effects of the Global Financial Crisis on the United States’ global health spending (McCoy, Chand, and Sridhar 2009)—and why it was so important to global health that the most pessimistic funding predictions did not come to pass (Youde 2018, 98-99).
Fourth, global health has consistently received bipartisan and broad public support—a rarity in contemporary American politics. Programs like PEPFAR consistently received widespread acclaim from both Democrats and Republicans, and more than half of all Americans believe that the United States should ‘play a major or leading role in improving health for people in developing countries.’ Furthermore, nearly 60 percent thought the United States was spending either the right amount or too little on global health aid (Kaiser Family Foundation 2018).
Finally, the United States has played important roles in mobilising responses to global health emergencies. During the Ebola outbreak in West Africa, the United States activated a variety of different parts of the government—including USAID, the Centers for Disease Control and Prevention, the National Institutes of Health, and the military—to provide supplies, personnel, and expertise to combat the outbreak. It was the country’s largest intervention in a global health crisis (Hossfeld, Hossfeld, and Dix 2018). Beyond Ebola, the United States has played significant roles in strengthening surveillance efforts around neglected tropical diseases, providing laboratory and diagnostic services, and training health care workers (Kaiser Family Foundation 2017). This does not mean that the US has supported every initiative, as its opposition to Health for All by 2000 helped to doom that initiative (Hall and Taylor 2003), nor does it mean that its interventions were motivated by altruism (Packard 2016). Its size and strength, though, provide it with an outsized ability to influence and shape global health initiatives.
The Trump Administration and Global Health
Even before Donald Trump became president, changes were afoot within the global health system. After years of rapid annual increases for global health, DAH has remained essentially flat since 2010 with an average annualised growth rate of only 1.0 percent (Institute for Health Metrics and Evaluation 2018, 15). Though some observers assumed that philanthropic organisations could compensate for any loss of government funding, Bill Gates has warned that the non-state sector lacks the resources to do so (Hodal 2017).
Into this uncertain environment, Trump has questioned the value of global health programs. During the Ebola outbreak in West Africa, Trump repeatedly took to Twitter to call for travel restrictions for people from Ebola-infected countries (in contravention of the International Health Regulations and WHO’s recommendations) and a ban on flights from West Africa to the United States (despite no such flights existing). He infamously tweeted that health care workers who cared for Ebola patients ‘must suffer the consequences’ if they fell ill. Trump tweeted about Ebola more than 50 times during the outbreak (Hatch 2017). Trump also campaigned on a platform that openly questioned the usefulness of multilateralism and foreign aid (Boon 2017)—two elements that have been central to contemporary global health governance. Shortly before his inauguration, Trump’s aides circulated a questionnaire to the Departments of State and Defense that asked, ‘Is PEPFAR worth the massive investment when there are so many security concerns in Africa? Is PEPFAR becoming a massive, international entitlement program?’ (Cooper 2017). The phrasing raised alarm that Trump was reframing the traditional understandings of PEPFAR and its role in sub-Saharan Africa.
Upon taking office, Trump’s actions did little to allay fears. In May 2017, Trump administration released its first proposed budget. It proposed cutting funding for global health activities by $2.2 billion, or 26 percent, for fiscal year 2018. This would include zeroing out birth control support for women in developing countries ($607.5 million), cutting international HIV/AIDS funding by 17 percent ($800 million), and reducing funding for anti-malaria programs by 11 percent ($81 million) (Aizenman 2017). With the United States government contributing roughly one-third of DAH, these cuts would have significant ripple effects and reduce the US’ global health spending to its lowest level in at least a decade (Schneider and West 2017). Though former Secretary of State Rex Tillerson spoke positively about PEPFAR and its usefulness in promoting American values abroad, the Trump Administration has sought to cut nearly a billion dollars from PEPFAR’s $4.5 billion annual budget, though Congress has resisted this move (Beaubien 2018). Cutting the international HIV/AIDS budget by $1.1 billion would kill at least 1 million people due to reduced access to medicines and prevention programs. Administration spokespeople have said that everyone currently receiving treatment will be able to stay on it, but they have not explained how that would be possible (Harris 2017). Additionally, Trump’s 2019 budget proposed cutting two-thirds of the funding for the Global Health Security Agenda, dropping its budget to $60 million. Such a cut would reduce early disease detection capabilities and force the program to reduce its operations from 49 countries down to 10 (Doucleff 2018).
Trump’s budget proposals went beyond reductions to specific health interventions to making far-reaching cuts to institutions and organisations that provide crucial support for global health. The National Institutes of Health (NIH) received a $5.8 billion cut, roughly 20 percent of its budget. Reducing the NIH budget reduces the number of grants available for developing treatments or vaccines for diseases like Ebola. More importantly, the NIH cuts would eliminate all funding for the Fogarty International Center, which supports global health training and research programs. The Centers for Disease Control and Prevention (CDC) would see $1.2 billion (approximately 20 percent) of its budget eliminated, despite the fact that Tom Friden, the CDC’s former director, warned that such cuts would make Americans and the world less safe (Belluz 2017a). Trump’s initial budget blueprint in 2017 made a vague commitment to creating some sort of federal emergency response fund, which could theoretically enable a quicker response to global emergencies, but the document was vague about whether this would be new money or a reallocation of existing funds (Belluz 2017b). Trump also proposed cutting the United States’ contributions to United Nations organisations, including the World Health Organization. The US government currently supplies nearly 19 percent of WHO’s annual budget, meaning that cuts would have a noticeable effect (Shendruk 2017). These cuts would also extend to the Global Fund to Fight AIDS, Tuberculosis, and Malaria, reducing the United States’ contributions to this major international multilateral health funder by 17 percent (Lagon 2017). The Global Fund disburses more than half of the global funds for both malaria and tuberculosis and more than 20 percent of the global HIV/AIDS funding (Institute for Health Metrics and Evaluation 2018, 51-66), and the United States government is the largest funder of the Global Fund’s operations. Cutting its contributions would have serious effects on the Fund’s abilities to support programs in low- and middle-income countries.
The Trump Administration’s global health cuts have not only targeted infectious diseases. Three days after taking the oath of office, US President Donald Trump issued a Presidential Memorandum Regarding the Mexico City Policy. Also known as the ‘global gag rule,’ this policy mandates that non-governmental organizations (NGOs) receiving funding form the US government cannot provide abortion services, provide abortion counselling or referrals, or advocate for liberalising abortion laws. This is not in and of itself surprising; Republican presidents have introduced similar executive orders since 1984, while Democratic presidents have rescinded them (Starrs 2017). What is different—and what caught international attention—was the scope of Trump’s memorandum. While previous presidents had applied the Mexico City Policy specifically to US family panning funds worth roughly $575 million, this version expanded the restrictions to nearly all US global health assistance, including programs on maternal and child health, nutrition, HIV/AIDS, and water and sanitation access—a total worth nearly $8.8 billion (Human Rights Watch 2018). In response, eight countries—including the Netherlands, Sweden, Denmark, Luxembourg, Finland, Canada, and Cape Verde—announced an initiative to raise funds to replace the shortfall caused by the Trump Administration’s policies. ‘(The gag order) could be so dangerous for so many women,’ declared Swedish Deputy Prime Minister Isabella Lovin when unveiling the response (Reuters 2017). These efforts have raised roughly $450 million, but that is a far cry from the total amount that the United States could withdraw (Edwards 2018). Critics of the Trump policy, and the global gag rule more broadly, argue that this strategy is more about American domestic politics than protecting the health of women internationally (Crane and Dusenberry 2004), implements rules that would be ruled unconstitutional if they were introduced in the United States (Crimm 2007), and threaten the efficacy of a wide range of global health initiatives (Singh and Karim 2017).
The effects of these proposed budget cuts go beyond the dollar amounts. While Congress has prevented many of Trump’s health-related budget cuts from going into effect, the budget reflects the White House’s priorities and values (Koren 2018; Zhang 2017). It is this idea, though, that worries observers. The budget blueprint is a reflection of Trump’s values and the avenues by which he envisions the United States influencing the global community. By cutting global health funding, Trump is essentially ceding American leadership in this space (Levitz 2017). George W. Bush even wrote an op-ed piece in the Washington Post in which he argued that programs like PEPFAR deserve support because they work and the show the US’ commitment to the rest of the world (Bush 2017). The political science literature, particularly the new institutionalist strain, emphasises that institutions—including budgets—express and reflect societal values (Lowndes and Roberts 2013, 186). By proposing cuts to global health programs, the Trump Administration presents the international community with a very clear understanding of the value it places on global health.
Trump’s actions may suggest that engaging his administration on global health is a lost cause, but that is the wrong approach for two reasons. First, the United States needs to stay seriously engaged with global health if international society is to maintain the health gains that have occurred over the past generation. Contemporary global health governance infrastructure depends crucially on the United States, so radical decreases would have far-reaching consequences. As noted above, philanthropic actors and coalitions of governments have proven themselves unable to counter the cuts the Trump Administration has proposed. The United States government has a unique role to play, and it is not one that others can easily replicate.
Second, Trump himself has made public statements that suggest at least a modicum of recognition of the importance attached to global health within contemporary international politics. In his 2017 address to the United Nations General Assembly, Trump proclaimed:
The United States continues to lead the world in humanitarian assistance … We have invested in better health and opportunity all over the world, through programs like PEPFAR, which funds AIDS relief; the President’s Malaria Initiative; the Global Health Security Agenda; the Global Fund to End Modern Slavery; and the Women’s Entrepreneurs Finance Initiative, part of our commitment to empowering women all across the globe (Trump 2017a).
During that same trip to the United Nations, Trump told a lunch for leaders from African states:
But we cannot have prosperity if we’re not healthy. We will continue our partnership on critical health initiatives. Uganda has made incredible strides in the battle against HIV/AIDS. In Guinea and Nigeria, you fought a horrifying Ebola outbreak. Namibia’s health system is increasingly self-sufficient. My Secretary of Health and Human Services will be traveling to Africa to promote our Global Health Security Agenda (Trump 2017b).
One can argue whether Trump genuinely believes these global health-related statements and whether his policy proposals belie his public rhetoric, but the rhetoric itself is worth acknowledging. At some level within the Trump Administration, there is at least tacit recognition of the validity of the global health governance system and the United States’ role within it. While it is impossible to know what is genuinely in any political leader’s head, it is entirely appropriate to look at what a leader is saying in a particular context to a particular audience (Krebs and Jackson 2007). The fact that Trump is saying these words about US leadership on global health in multilateral settings suggests that there is some recognition of these values.
Given these realities, the challenge becomes identifying a way to encourage the Trump Administration to engage with global health on some level. Interestingly, this is exactly where securitisation could be a useful tool for the international community. Securitising health could offer a logic that would encourage Trump to support global health.
Securitisation as Strategy for Support from Trump Administration
Securitising global heath may provide a strategy which, while not without its own trade-offs, could provide a rationale to the Trump Administration to maintain, if not even increase, the United States’ engagement with global health.
Securitisation is often framed in negative terms; securitising an issue removes it from the realm of normal political discourse, sets up a us-v-them dichotomy, and necessarily militarises it (De Waal 2014). While there are certainly strains of this thinking within securitisation theory, securitisation also contains emancipatory opportunities within it. Securitisation can disrupt established patterns and relationships, but it does not require the abrogation of established principles and practices (Roe 2012, 260). It can provide the basis for holding political leaders accountable for living up to their pledges by establishing certain promises about the government’s policies toward the referent object of security (Floyd 2011, 428). Securitisation responds to and operates within unique domestic political and social contexts, which in turn drive government reactions to it. As a result, trying to adapt a global norm into any particular national context will depend on finding a manner in which that norm will resonate with local audiences (Curley and Herington 2011, 160). In this way, securitisation is less of an effort to militarise global health or remove it from the political realm and more as a pragmatic practice that responds to the dynamics that exist within a given context (Balzacq 2005, 172).
How could securitisation be used as a force for good for encouraging the Trump Administration to engage with global health? Drawing on Trump’s own rhetoric, three possible avenues exist. First, securitisation could potentially appeal to the Trump Administration’s economic interests. Disease outbreaks are incredibly expensive and work against promoting economic growth and development. The World Bank estimates that the Ebola outbreak in Guinea, Liberia, and Sierra Leone decreased the gross domestic product (GDP) in those three states alone by $2.2 billion in 2014 and $1.6 billion in 2015 in the best-case scenario models (World Bank 2014). Those figures do not include the costs associated with redirecting government expenditures away from other areas, the loss of foreign and domestic investment, or lost trade and tourism revenue. This is not unique to Ebola. The SARS epidemic in 2003 reduced global GDP by $54 billion (Lee and McKibben 2004). The emergence of cholera in Peru in 1991 decreased national revenues by at least $700 million in that year alone, and an outbreak of plague in Surat, India, in 1994 cost an estimated $1.3 to $1.7 billion (Price-Smith 2001, 108). These figures merely reflect changes in the GDPs of the countries where the outbreaks occurred; they do not reflect the subsequent costs for disease surveillance and treatment or longer-term depressed economic performance. Spending money upfront bolsters the global economy and reduces the likelihood that foreign governments and international organisations will need to ask for funding in emergency situations. This ties in with Trump’s recognition at the United Nations in 2017 that prosperity demands health.
On another level that may appeal to Trump’s business inclinations, healthier people will be better workers. If you are sick, you will either miss work or be less productive. This was part of the rationale that motivated the Rockefeller Foundation’s disease control and prevention efforts in the early twentieth century; improved health would lead to increased business profits (Brown 1976). This line of thinking ties in with some contemporary critiques of philanthrocapitalism, arguing that corporate social responsibility and philanthropic activity is less about alleviating problems and more about allowing companies to hide their bad actions behind a veneer of ‘doing good’ (McGoey 2015; O’Manique and Rahman 2013). One can see this sort of logic at work even within Trump’s Cabinet. Before he became Secretary of State, Rex Tillerson was the CEO of ExxonMobil. The ExxonMobil Foundation, the oil company’s philanthropic arm, has made malaria one of its top concerns. Roughly 80 percent of its annual global health grants (approximately $15 million each year) funds malaria prevention, treatment, and elimination (Moses 2014). It is possible that the ExxonMobil Foundation has decided to focus on malaria because it sees a gap in global health financing, but its decisions are likely driven by its corporate patron’s interests. There is a strong overlap between regions where malaria is endemic and regions where ExxonMobil drills for oil. High rates of work absenteeism and increased health costs make it more expensive to drill for oil and thus reduce ExxonMobil’s profits. As a result, the company sees it as in its long-term economic profit interests to address global health concerns as a way to reduce health care costs and worker absenteeism. There is a certain crassness in appealing to the economic bottom line to motivate involvement with global health issues (and Tillerson’s departure may give this argument less weight), but this is driven by recognising the current domestic political and social context and finding a message that will resonate with key policymakers.
Second, securitisation could encourage greater investment in health systems around the world. Trump has repeatedly shown an aversion to people with infectious diseases coming to the United States. That was well-illustrated by his tweets about the one travel-related case of Ebola that appeared in the United States and the furore over quarantining health care workers who had served in West Africa regardless of whether they were exhibiting any symptoms of illness. If the Trump Administration wants to keep people from coming to the United States to seek treatment, then it behoves them to support the strengthening of health care systems in those countries to identify potential outbreaks at the beginning and provide frontline treatment to keep any outbreak from spreading beyond its borders.
Rather than framing this as an us-v-them dichotomy, it might be more useful to think of it as expanding access where people live. There could be additional benefits to this framing in that it would encourage the diffusion of medical information and technology. The more readily people can access high-level diagnostic and laboratory services where they are, the less need they will have to travel across international borders and potentially spark a cross-border epidemic.
Third, securitisation may provide the logic for the Trump Administration to see value in using the military to provide logistical and operational support during disease outbreaks. During the Ebola outbreak, President Obama mobilised the United States military to assist with the coordination of the government’s involvement, lead logistical and staging efforts, build Ebola Treatment Units, and provide direct medical care and assistance. He described this as part of a whole-of-government response by the government and drawing on areas of specific expertise held by the military (White House 2014). More than 5000 military personnel from at least five countries and the African Union deployed to West Africa during the outbreak, primarily focusing on logistics, constructing Ebola Treatment Units, and training local health care workers (Kamradt-Scott et al. 2015, 26). Trump responded by calling the military’s involvement in the Ebola response ‘dumb’ (Yong 2016).
The involvement of military members in responding to Ebola—or other global health crises—does not representation the militarisation of global health or the equating of securitisation and militarisation. Instead, it is a pragmatic response to the logistical and personnel requirements in emergency situations. Even Doctors Without Borders openly praised the involvement of militaries in supporting the international response to Ebola (Hussain 2014). Interviews with military officials involved with the Ebola response reveal, too, that armed forces have some particular skills that may be useful in responding to disease outbreaks, but that the military lacks the abilities or the desire to completely oversee a national response (Kamradt-Scott et al. 2015). Foreign and domestic military involvement in responding to Ebola was largely helpful, but it is not a panacea and requires coordination with a wide range of other involved actors (Kamradt-Scott et al. 2016, 104).
Securitising global health would provide a more direct route for the Trump Administration to understand the role that the military could play in supporting other responders. Simultaneously, to avoid putting too much responsibility on the military’s shoulders, it would be crucial to ensure that other responders—such as CDC and WHO—have sufficient resources so that the military does not become the default global health emergency responder. Given Trump’s professed support for the military, this would provide the military with an additional mission and elevate its international status.
To some degree, there already exists a blueprint for embracing this strategy. The Obama Administration committed $1 billion in 2014 to work on global health matters in 49 different countries through the Global Health Security Agenda (GHSA). GHSA sought to direct attention to disease outbreaks that ‘not only threaten public health but can represent transnational security threats requiring new collaborative responses’ (Katz et al. 2014, 231). Unfortunately, in early 2018, the CDC announced that it would have to end GHSA operations in 39 of 49 countries because of an 80 percent cut in funding for the program (Drash 2018). The Trump Administration’s decision was not necessarily a complete surprise. Writing at GHSA’s beginning, Gostin and Phelan remark, ‘With a presidential election in 2016, the next incumbent could pivot in a different direction’ (2014, 27). Trump has shown a disdain for programs championed by Obama, but a more overt securitisation effort might allow the Administration to make the program by more strongly emphasising its security, as opposed to humanitarian, elements.
It is important recognise that securitising health brings its own significant baggage. Securitisation can distort agendas and lead governments to ignore other important issues. It is not necessarily an ideal solution, and should not necessarily be adopted in all circumstances. The ideas presented here are more of a pragmatic recognition of the changes in the United States’ changing political and social contexts, reflecting Balzacq’s (2005) argument that securitisation can be a pragmatic act occurring within its own unique combination of circumstances. If the alternative is letting global health drop off the United States’ agenda, seeing the United States cede its leadership within the global health space, and watching the advances made over the past quarter-century reverse, then securitisation may be the best option for maintaining some degree of engagement. Furthermore, securitisation is not a one-time decision. Securitisation is part of an ongoing, contested process (McDonald 2008, 578-579). Framing health as a security issue now does not mean that health will or should be framed in that manner for all time. It is a response made within a unique context, and should be appreciated as such.
Conclusion
The Trump Administration presents perhaps the most significant challenge to the contemporary global health governance system. Trump himself has openly questioned the efficacy of foreign aid, multilateralism, and the fundamental bases of global health governance into question. The international community can ill afford to reduce its vigilance on global health, but the Trump Administration seems to be calling for just that. In order to counter these messages, this article suggests that the securitisation of health may actually contain positive opportunities for the maintenance and expansion of global health governance. Securitisation may not be the ideal framing for many global health advocates, but it may be the most pragmatic and appropriate response in the current political and social context in which the United States government is operating. Securitisation may provide a rationale necessary to encourage continued political, economic, and financial engagement on these issues. Securitisation may not be the right approach for all governments or in all situations, but it may prove a useful frame that will resonate with the current American presidential administration.