Introduction

Our understanding of what constitutes a threat to security has been increasingly debated since the late 20^th century. Whereas most conceptions of security derive from the Cold War era where large armies with nuclear weapons faced off against each other, with the end of the Cold War, new conceptions of security have grown increasingly popular. One relatively recent focus has been on health security, how to define it and whether the decision to define health as a “non-traditional” security issue is a wise one. I draw on two examples – one in the Middle East and one in East Asia - to explore the pros and cons of securitization.Does framing pandemic threats as a high politics, non-traditional security threat increase or decrease the likelihood of an effective global response to future pandemics?

The Threat

Facilitating the spread of newly emerging infectious diseases is the fact that the overall human population is growing and spreading out, bringing humans into closer contact with hitherto sheltered wild animals. This process is exacerbated by deforestation, a growing reliance on factory farms and live animal markets, rapidly growing human mobility and climate change. Globalization has also played a role. Whereas the 1918-1920 Spanish Influenza infected approximately one third of the global population over an extended period, initially spreading by troopship during WW I, the 2009 H1N1 outbreak infected between 20-40 percent of the global population, spreading across the globe on international flights in only five weeks.5 COVID-19 spread even more rapidly, with occurrences being reported by countries across the globe within a month of the first case being reported in Wuhan China.6

The WHO Global Agenda declares that “shared vulnerability to health security threats demands collective action…”7 Echoing these statements in its Global Health Partnerships publication, the USCDC asserts that “the scope and intensity of global health challenges ensures that no single country or agency can work alone to meet them”.8 Indeed, as with any pandemic threat, effective response requires both domestic and coordinated international cooperation. As noted by Heymann and Rodier, to protect the global population from emerging and epidemic-prone diseases, the international community requires strong defense systems at both the national and international levels. Referring to the SARS CoV-1 (2003) example, they note the broad consensus in the international health community that “inadequate surveillance and response capacity in a single country can endanger national populations and public health security of the entire world”.9 Clearly, it is beneficial to increase the international focus on pandemics and to encourage international cooperation on pandemic response. An important question is what strategies will work best to facilitate a global cooperative response to pandemic disease? To address this question, I turn first to a discussion of how pandemics are framed in the security literature.

Framing the Pandemic challenge

How we frame an issue influence how we approach that issue. Schon and Rein define frames as “underlying structures of belief, perception and appreciation.”10 Different parties may view any given situation with conflicting frames -distinct perspectives that influence how they approach an issue and seek to resolve it. The very terminology we use contributes to establishing a frame and influences our approach to resolving the issue identified. With regards to pandemic threats, how we choose to frame them will influence the nature of state responses, international cooperation, and the willingness of actors to make concessions. As Waever suggests, how we elect to frame health (in this case, as a security issue or not) will influence international governance of pandemic response for better and for worse and therefore must be explored.11

Historically, health issues were not considered high politics – issues of security and sovereignty. After all, traditional definitions of security refer to protecting the territorial integrity, political institutions and national sovereignty of states from external physical threats.12 Rather, as during the Cold War, health was considered a low politics issue, one that lacks great manifest political or military import, being technocratic in nature and irrelevant to either national or international security. 13 However, following the conclusion of the Cold War, and the eruption of new and often frightening pandemics, a move to expand global definitions of security to include health began. In 1946, the WHO constitution stated that “the health of all peoples is fundamental to the attainment of peace and security”.14 In 1994, the United Nations Development Program Human Development Report focused on security as symbolized by “…protection from the threat of disease, hunger, unemployment, crime, social conflict, political repression and environmental hazards.”15 In 2000, while speaking before the UN Security Council opening session, then Vice President Al Gore called for an expansive definition of security to include emerging and re-emerging infectious diseases.16 Also in 2000, the US National Intelligence Estimate for the first time classified infectious disease as a threat to national and global security, a statement repeated in the 2010 US National Security Strategy. In 2007, the WHO referred to the H5N1 virus as the “most feared security threat” defining Human Security as “the activities required, both proactive and reactive, to minimize vulnerability to acute public health events that endanger the collective health of populations living across geographical regions and international boundaries”. In making this statement, the WHO pushed infectious diseases towards the realm of non-traditional security and high politics.17 Non-traditional security incorporates non-military threats to the survival and well-being of people. By 2002 the call for securitizing extended to include the threat of even naturally occurring pandemic influenza. After all, the threat to health security remained regardless of the source of threat.18

Susan Peterson identifies two main causal mechanisms by which infectious diseases may threaten security. First, infectious diseases may alter the balance of power among states resulting in economic or political instability that may foster conflict. Second, infectious diseases may be used deliberately as weapons of war or may inadvertently cause illness among troops thereby undermining their ability to function.19 Linking such diseases with national security – “securitizing” health – means using security related strategies and tactics when addressing health concerns. Doing so is likely to raise awareness among both government officials and the public in general and, as a security challenge, will draw greater investment by the government. As Caballero-Anthony argues, framing infectious diseases as national security-related enables governments and populations to better prepare for sudden eruptions of pandemics that may threaten lives and even the state’s survival.20 Officials and academics involved in disease control and response will enjoy greater prestige and will likely find themselves involved in an increased number of high profile international meetings and conferences to address the threat.21 In short, linking pandemics to security will increase awareness, “raise the stakes,” capture scarce resources and invigorate the national and international response.

The US “war on drugs” is an example of the impact of framing. Here the US effort to control movement into the US of illicit drugs was described as a “war”. As such, the government securitized and thereby raised the profile of the drug challenge, increasing attention and resources for the effort to eliminate the threat. Similarly, the Taiwan CDC(TCDC) decided to describe efforts to contain and control epidemic diseases in Taiwan as a “war on disease.” By securitizing epidemic diseases, the Taiwan CDC explicitly framed these as high profile, important security challenges requiring serious attention and support.22 Many other countries followed the same strategy – declaring a War on COVID.

However, there are potential drawbacks to “securitizing” pandemics as well. If pandemics are framed as security threats, they become associated with traditional security issues, including state sovereignty and national security. Securitization turns health into a foreign policy issue that may be exploited by states to achieve wider political objectives.23 Compromise and cooperation at the international level – key aspects of effective pandemic response – may become more difficult as narrow self-interest becomes the basis for action. States will become more likely to act only if and when the infectious disease is perceived as directly threatening the interests and national security of the state. Furthermore, states are more likely to respond by garrisoning behind national borders to protect their citizens from the external threat.24 Finally, by “securitizing” pandemics, the more traditional conception of security is potentially diluted, requiring a new vocabulary to capture more immediate threats to the state.25 Can the linkage between pandemics and security be over-used and as a result actually weaken the concept of security? Does raising pandemics from a public health and development challenge requiring a humanitarian response to a security challenge increase the possibility that international politics will interfere with effective response?

In short, does securitizing pandemic response enhance or weaken international pandemic response? If the former, there may be room for this approach. If the latter, framing pandemics as a security issue maybe unwise.

International Cooperation in Pandemic Preparedness and Response

The main international actor in pandemic preparedness and response is the WHO (World Health Organization) which came into existence, replacing its League of Nations predecessor, in 1948. In 1951 the WHO adopted the International Sanitary Regulations first developed in 1851, changing and renaming them the IHRs (International Health Regulations) in 1969. These were most recently updated in 2005, coming into force in 2007. Under the new IHRs, the 194 WHO members are required to notify the WHO Secretariat of any public health emergencies of international concern. The IHRs also expanded from covering only three diseases to more than fifteen, with the option existing to add additional diseases that might arise. All members are legally bound by the IHRs though the WHO lacks real enforcement powers beyond “naming and shaming”. The WHO also established six WHO regional surveillance networks. The WHO’s responsibility is to mobilize the financial, technical, and human resources required to respond to outbreaks, while providing advice and information to governments, the media and the public in general.26

Another important international institution is GOARN - the Global Outbreak Alert and Response Network - formalized in 2000. Part of the WHO, GOARN includes over 140 participants. It identifies and responds to over 50 outbreaks in developing countries each year, providing resources to the WHO which can then coordinate responses. GOARN works closely with the WHO’s Global Influenza Surveillance Network, established in 1947 with a focus on vaccine development and distribution. 9

Additional contributors to international pandemic preparedness and response include the Global Public Health Intelligence Network established by the Canadian government in cooperation with the WHO in 1997. This network monitors international media for information on outbreaks, terrorism and other natural or human-induced disasters. 27 Also contributing to surveillance and response is the US GEIS - Global Emerging Infectious Surveillance and Response System. GEIS has over 35 worldwide partners to monitor and research infectious diseases, provide local training, coordinate information, and notify GEIS laboratories in the US of any potential threats.28

These by no means describe the full extent of global organizations (governmental, intergovernmental and non-governmental) that have an active role in pandemic preparedness and response. Thus, ProMED (the program for monitoring emerging diseases) is a broadly accessible internet-based electronic notifications system encompassing approximately 185 countries and over 80,000 members(as of 2022). The UN Food and Agricultural Organization, the UN Children Fund, the World Bank, the World Animal Health Organization (OIE) and more participate.

As Taiwan is not a UN member nor a member of the WHO, it lacks membership in these intergovernmental organizations. As such, its participation in global pandemic response initiatives is constrained. However, as the MECIDS (Middle East Consortium on Infectious Disease Surveillance) example illustrates, it is not always necessary to be a formal member of the international community to participate in international pandemic response institutions.

The MECIDS

Long notes that the MECIDS, established in 2003,includes one non-state actor (non-member of the WHO) – the Palestinian Authority – as well as Jordan and Israel.28 Drawing on this example, he also asserts that successful cooperation can be achieved even among enemies. The relationship among these three began informally, based largely on unwritten understandings, and with the goal of maintaining equality among participants. The Chair rotates among all participants, with the organization’s functions divided up geographically among all three. Drawing on the IHRs, the organization facilitates cooperation and information sharing to prepare and respond to disease outbreaks and pandemics. Participants are drawn from governments, non-governmental organizations, academic institutions and the private sector. Thus, the Ministries of health for each country participate along with local universities and institutes. The MECIDS strives to remain apolitical, receiving no funding from the governments of the organization’s three participants, but rather from inter-governmental and non-governmental organizations, as well as the private sector, with the Nuclear Threat Initiative (NGO) a primary funding source.

Long argues that this organization’s success derives from creating institutions that are inclusive, practical, equitable and efficacious, incorporating formerly excluded actors while building trust among participants. MECIDS fulfills an important public health task while also thickening ties, strengthening relationships and fostering trust, mutual support and resource sharing.

Success is further bolstered by the lack of endorsement by any of the relevant heads of state or foreign ministers, thereby avoiding pressures for political posturing. Relationships are personal and professional, enabling recognition of shared goals and values without being trapped in the traditional, fraught, political narrative of high politics, security, threat and competition.

Finally, success derives from a recognition that, as one participant explained, “you are only as strong as your neighbor”.28 In other words, cooperation is recognized by all participants as beneficial to the safety of their own populations because their proximity increases the likelihood that a disease in one of the members is likely to quickly cross into the jurisdiction of the other two.

ASEAN and ASEAN + 3

An important East Asian example of an organization working on pandemic response is ASEAN (the Association for Southeast Asian Nations) and its expanded format, ASEAN + 3 (China, South Korea and Japan).29 In the wake of the 2002-03 SARS outbreak, ASEAN members established four key pandemic-related forums in an effort to strengthen both domestic and regional pandemic related surveillance and response capacity. Among the groups established were: 1. The Expert Group on Communicable Diseases; 2. The Highly Pathogenic Avian Influenza (HPAI) Taskforce; 3. The ASEAN plus Three Emerging Infectious Disease Program; and 4. The Regional Forum for Control and Eradication of HPAI.21 These groups facilitate information sharing on emerging infections of international concern and national practices in member countries.

In 2002, the ASEAN+3 members signed a joint declaration highlighting the need for extensive cooperation in coping with non-traditional security threats that, with the outbreak of SARS CoV-1, came to include pandemic diseases.30 At the conclusion of the 2004 annual ASEAN summit for health ministers, the joint declaration included commendation for work being done by the expert group on communicable diseases in expanding and improving the ASEAN + 3 Action Plan on Prevention and Control of SARS and other infectious diseases. Conspicuous in its absence from ASEAN and the ASEAN+3 forum is Taiwan.

Taiwan’s place in the international public health community

As already noted, effective pandemic response requires cooperation among all countries in the international community. Ideally, all countries will share information regarding potential pandemics within their own communities while also providing technical and other support. Not only is this an ideal, but it is a requirement of the International Health Regulations (IHR). Also, all countries should enjoy equal access to information regarding outbreaks, have access to WHO expertise and the expertise of participating WHO members. WHO member countries have these resources as well as access to flu strains and health specialists who travel to member countries to assist in epidemic response.31 Members also participate in the World Health Forum (a gathering of all member countries) and in regional forums where information and ideas are exchanged. WHO Country-members also have access to information regarding epidemic developments that are not available to the general public. These reflect just a few of the benefits deriving from WHO membership. By actively participating in the WHO and adhering to the IHRs, member states form a web of communication, information sharing and support in the case of a potential pandemic. Of course, to participate one must be a member, and to be a member one must be recognized as a state.

Taiwan, officially the Republic of China, was replaced as a member of the World Health Organization in 1972 by China, officially the People’s Republic of China at the same time that Taiwan lost its UN membership. Now categorized by the WHO as a province of China, this self-governing democracy of 24 million people no longer benefits from official, state level, interactions between its health officials and medical professionals, and the WHO. WHO organized workshops and forums, including those on topics such as disease diagnosis, effective monitoring, and control of emerging infectious diseases have become inaccessible to Taiwan representatives.

In addition, Taiwan has lost its eligibility to access controlled early warning or risk assessment information regarding emerging infectious diseases. Even access to virus samples and equipment stockpiles has been withdrawn by the WHO. Officially, any information that Taiwan might seek is to be obtained through the Mainland Chinese government. From Taiwan’s perspective, this has become an untenable situation.

Taiwan has adapted to its status in global pandemic response by fostering informal relationships with important regional and international actors. Taiwan public health officials work closely with the US CDC and the Japan equivalent. Taiwan also draws heavily on open-source information as made available through organizations such as ProMed and CIDRP (the Center for Infectious Disease Research and Policy).

After failed efforts from 1997 to 2008, Taiwan’s situation improved somewhat when in 2009 China supported Taiwan’s application for observer status at the World Health Assembly. Under the title “Chinese Taipei”, this new status ensured that Taiwan’s point of contact for epidemic information sharing was accepted, and that Taiwan could access the WHO’s secure event information site. WHO officials were permitted to visit Taiwan, and within certain constraints, Taiwan’s public health officials were permitted to attend WHO committee meetings dealing with PHEICs.

This greater openness to Taiwanese engagement in the WHO followed the rise to Taiwan’s presidency of Ma Ying-jeou in 2008. A proponent of closer cooperation with China, Ma Ying-jeou facilitated expanding economic and tourism ties between China and Taiwan.

However, at China’s insistence, Taiwan lost its observer status in 2016 when Tsai Ing-wen, Taiwan’s current president and a proponent of greater autonomy from China, was elected. By 2020, despite efforts to diversify, Taiwan’s exports to China constituted over 43% of its total exports while China has been unsuccessful at diversifying away from high-technology Taiwanese products it requires for its own economic development.32

In 2021, citing Taiwan’s extensive experience in pandemic management and its ability to assist the international community in managing COVID-19, members of the G-7 sought to have Taiwan’s observer status reinstated. This effort was blocked by China which argued that as a part of China, Taiwan’s interests must be represented by China alone.33 China’s sensitivity to even the perception of Taiwan independence was made starkly evident by its response to the August 2022 visit to Taiwan by US House Speaker Nancy Pelosi.34 As Xi Jinping has made clear, Taiwan’s status is a question of state sovereignty and China’s internal affair, and any moves by Taiwan to increase its international status, such as gaining status with the WHO, would not be tolerated.

The Taiwan-China nexus is of particular importance to pandemic control. China has in past and continues to be a major source of emerging infectious diseases. In China’s southeast can be found high human population densities, a rich diversity of wildlife and a warm climate – conditions conducive to the spread of emerging infectious diseases. According to the US National Intelligence Estimate, “particularly Chinese agricultural practices place farm animals, fowl and humans in close proximity and have long facilitated the emergence of new strains of influenza that cause global pandemics.”35 The close economic and tourism ties between Taiwan and China has resulted in increased travel between them, with the result that they form almost “one unit” in terms of pandemics.36

Discussion

Under CCP General Secretary Xi Jinping, China has boosted its nationalistic rhetoric, tying successful Chinese “rejuvenation” to “re-unification” of China with Taiwan. This narrative has been inculcated into Chinese society to such an extent that even should the Chinese leadership wish to do so, it would be politically difficult to take a softer line on Taiwan’s status.37 Even in the case of public health – normally considered a “low politics” issue –China’s refusal to allow Taiwan to enjoy WHA observer status demonstrates a conflation of public health with sovereignty issues and hence “high politics”. In essence, China has raised the public health component of the China-Taiwan relationship from a “low politics” to “high politics” making any cooperation difficult.

Does framing pandemic threats as a high politics, non-traditional security threat decrease the likelihood of an effective global response to future pandemics? Or would the global response to future pandemics be stronger if framed as a public health and development issue? The examples of MECIDS and the Taiwan-China relationship suggest that raising the profile and the stakes associated with pandemics – shifting pandemics from low to high politics – serves to undermine international cooperation on pandemics and in the process weaken the international community’s capacity to manage pandemics.

That China and Taiwan are highly interdependent is clear. The quick movement of COVID-19 from China to Taiwan reflect this reality. Undoubtedly there is great potential benefit not only to China and Taiwan but to the international community to be derived from incorporating Taiwan more closely into international pandemic preparedness and response networks. To build this level of incorporation, enhancing relationships and trust is essential. However, if pandemics are framed as high politics, the possibility that a situation similar to that found in the Middle East will become far harder to achieve.

Taiwan has seen its access to and participation in the international public health community swing from full participant to non-state observer to its current exclusion. China has used Taiwan’s World Health Assembly observer status as a political weapon, penalizing the island after it elected a less China-friendly president. The outcome is weakened pandemic preparedness in Taiwan, in China and internationally. While shifting pandemics from low to high politics may increase its profile and potentially the resources directed to pandemic response, the costs in terms of global cooperation are significant.

Conclusion

There is an ongoing debate about the benefits and drawbacks of “securitizing” health. On the one hand, there is a strong argument to be made that in an era where pandemics like Ebola, H1N1, SARS CoV-1, MERS, SARS CoV-2 and Monkey pox have returned with a vengeance, public health challenges must be given a higher priority. Institutions such as the WHO should be given greater financial support and international influence and countries should sign treaties that facilitate deeper cooperation in advance of a novel pandemic. Securitizing health – raising it from low to high politics, will contribute to achieving this end. Once health is considered a security issue, governments will prioritize health, investing more heavily and taking more seriously any health-related challenges. However, as the MECIDS and Taiwan-China examples demonstrate, there are notable costs to securitization. Most importantly, turning health into a matter of high politics raises the profile of any health threat. Where in the past governments might allow low-key, low-level cooperation among otherwise unfriendly neighbors (as in the Israel-Jordan-Palestinian Authority case), such cooperation becomes far more difficult when the stakes are raised as occurred between China and Taiwan.

There is new and increasing global awareness of the growing threat to the international community constituted by pandemics. It would be a grave error to ignore this threat and to under invest in preparing for and responding to current and future pandemics. However, steps to securitize pandemics have the potential to achieve the opposite outcome. Leaving pandemics, and health in general as low politics decreases the stakes for politicians and for state governments, enabling low-key cooperation even among unfriendly neighbors. Given that pandemics know no borders, such cooperation is critical to future global pandemic preparedness and response.