The Pandemic Threat

Talk of plagues in these gleaming modern days drags the mind back in time to the pustules, exorcisms and corpse pits of the Dark Ages. Unfortunately, the issue of global pandemics is very much one of the future; it could even turn out to be the issue of our times.

The attempt here is to look at the role of securitisation in dealing with the looming likelihood of a biological apocalypse that could leave 30-70 million people dead (according the World Health Organisation). Discussions of the dangers the globe faces from emerging infectious diseases (EID) most often take place on a backdrop of human security. The individual is taken as the referent and the threat to his personal well-being is assessed. This widening of the security agenda from the traditional boundaries of national security to include the welfare of every human being tends to blur the pragmatic questions governments must ask: when does an emerging infectious disease become a threat to the survival of the state? What security issues are particular to biological threats? How do governments respond to a situation of this kind?

It cannot be assumed that everything that is detrimental to the literal health of the nation will automatically become a threat to the political independence and the territorial integrity of a country. Disease generally belongs to the sphere of public health. However, there are immediate points of intersection with traditional security concerns. The effect of epidemic disease on military conflicts has been noted since the Peloponnesian Wars, and scenarios involving biological weapons also straddle both spheres. Under what circumstances then, can a naturally-occurring epidemic in the civilian population become a threat to the survival of the state?

This depends firstly on the nature of the pathogen — its virulence and speed, who is infected and where it occurs. The mere existence of a disease will not be an issue of national security, but the abnormal behaviour of the disease – an epidemic – could become one. The dangers posed by an EID epidemic could, then, be divided into primary and secondary threats. Primary threats would be immediate challenges to national security: attack by a biological weapon; an army decimated by disease. Secondary threats would be the longer-term consequences that, if not managed correctly, would have the potential to challenge the survival of a sovereign state. These could include a large civilian death toll affecting the workforce and productivity, social upheaval and trauma leading to conflict, a crisis of legitimacy for the government. . . While the threat is global, it may not be uniform. In some cases, the prosperous nations may even be more vulnerable to the effects of disease epidemics than developing or declining states.

Emerging Infectious Diseases (EIDS) are considered to be infectious diseases in humans that have increased in incidence in the last twenty years, or that threaten to do so. The Centre for Emerging Infectious Diseases (CEID) divides them into four categories: new infections resulting in the change or evolution of existing organisms (for example H5N1 or ‘Bird Flu’); known infections appearing in new geographical areas or in new populations (the spread of Malaria for instance); previously unrecognised infections appearing as a result of ecological transformations (Ebola, possibly HIV/AIDS); old infections re-appearing due to antimicrobial resistance or a breakdown in public health measures (Polio). Note the potential crossover of health and traditional security issues in the last category, where a failing or troubled state is unable or unwilling to stop the re-emergence of an existing disease.

Polio is a useful case-study. While simple vaccines have almost eliminated polio from the planet, it is re-emerging in some Muslim countries. Nigeria and Pakistan , for example, have a high resistance to vaccination because of deep suspicion that inoculation is part of a western plot to spread AIDS or to make Muslim girls infertile. The recent (May, 2005) polio outbreaks in Java , Indonesia , were thought to have been come from infected pilgrims returning from the haj, where they would have had contact with Muslims from all over the world.

In the recent ASPI paper on infectious disease, Peter Curson points out that in the last thirty years, around forty new infections have been recorded, most as a result of zoonoses, whereby a disease that occurs naturally in animals evolves to the point where it can infect humans. These include Ebola, Legionnaires Disease and Mad Cow Disease. Using the CEID categories, it is possible then that old infections such as malaria, Dengue fever and polio could be added to the list. Warmer global temperatures may enlarge the geographical area in which mosquitos (vectors) live, and so spread Dengue and Malaria to previously unaffected areas.

The main EIDs to date however are HIV/AIDS, SARS, and H5N1 or ‘bird flu’. These are diseases for which no human has proven immunity, and for which there is limited knowledge about treatment. Unlike the mosquito-borne diseases, these three are not climate-sensitive and so have the potential to affect any country in the world; they also share a high mortality rate. As of February 2005, forty-two out of fifty-five cases of laboratory-confirmed H5N1 have been fatal after direct transmission of the virus. HIV/AIDS is a global problem, but it is particularly prevalent in the ex Soviet republics, areas of Southeast Asia , India and Africa – especially sub-Sahara. Many of these regions also suffer from epidemics of other infectious diseases such as cholera and malaria. This is important as ‘waves’ of disease can further weaken a government’s ability to respond to new outbreaks.

The virulence of the ‘big three’ is undisputed, but it is important to note the characteristics that are particular to each disease: mode of transmission and speed of death. HIV/AIDS is not airborne, nor can it be transmitted by droplets or skin contact. It is a slow killer and symptoms do not show for some time. This makes it easier to avoid – as contagion is linked to behaviour — and yet extremely effective in spreading as hosts may be unaware they are affected. The SARS virus is transmitted at close range, most effectively through coughing and sneezing. However these symptoms set in at the later stages of infection and this makes it possible to identify an infected person before they are at their most contagious. Avian Influenza (H5N1), once airborne, will travel from host to host as a virus. This means it can pass through common surgical masks. It will take up to ten days for the onset of symptoms, during which time the person is highly contagious. This leaves plenty of time for the virus to spread undetected.

Estimates on the number of people who would be infected by a new influenza pandemic vary but the Centre for Disease Control puts the number at over a billion. (Compare this to the forty-two million people currently estimated to be infected with the HIV virus). The different virus characteristics must be noted because the responses need to be disease-specific to be effective. SARS cases appearing in Canada were traced back to an infected 65 year-old doctor in Guangdong . National boundaries are irrelevant to an EID, but not to the practical solutions needed to combat them. These must be trans-national in scope and the capacity for containment is key.

The long-term effects of ‘creeping’ diseases such as HIV/AIDS are being felt in Russia and sub-Saharan Africa , where infection is beginning to impinge on the strength, productivity and stability of the nation state. One quarter of South Africa ’s police force is thought to be infected, with severe law and order implications. In Botswana , close to 90% of boys now aged fifteen will become infected during their lifetime. Disease will mingle with existing tensions and deprivations to rock stability in the region, perhaps even to the point of total collapse in some areas. Soldiers who are dying will have little motivation to fight for their country, for example, and waves of epidemic refugees would simply buffet that stability further.

In Russia , AIDS infections are rising faster than in any other country in the world. Russia ’s birth rate is low – unlike in Africa — and the population is declining. The AIDS epidemic is likely to exacerbate economic problems, undermine military capabilities and could seriously shake the government’s legitimacy. Some scenarios suggest AIDS could so weaken the capabilities of a state’s conventional army that it would rely increasingly on nuclear weapons. . .

Although these cases are at the worst end of the spectrum, they are useful in trying to understand how an extreme manifestation of even a slow-moving, non-airborne disease has the potential to affect national security. With airborne diseases, the implications emerge almost immediately. SARS cost the Asia-Pacific region an estimated $40 billion — an epidemic that lasted six months. The economic impact of the disease was exacerbated by fear and confusion, but this is the ‘value-added’ factor that will accompany any new and fast-spreading disease. With H5N1, the epidemic could last up to three years and would be infinitely more costly, and more deadly.

The effects of EIDs in all countries – and even within countries – will not be the same. Infection as a security challenge will likely depend on the particular disease, as its characteristics will determine how far and how fast it spreads, who its victims are, and the ratio of infection to mortality. Aspects of modern living encourage the spread and incidence of infectious disease. Increasing urbanisation brings more people into cities, side-by-side with animals, shanty towns next to big hotels. Changes in social patterns and behaviour with regards to sex and drug use is particularly associated with HIV/AIDS but not limited to this particular EID. Warmer global temperatures could increase the number of people exposed to disease-carrying mosquitoes. Rapid travel in small aircraft cabins, and increased trade and commerce facilitate a lightning world-wide spread. Modern medical practices can also be part of the problem: the overuse and misuse of antibiotics has created resistant strains of disease, or ‘super-bugs’, as well as an increase in invasive procedures. Most of these factors affect a wealthy western populace as much – in some cases more – than developing countries.

While prosperous nations have an arsenal of better medicine, stronger government, better health systems, education and communication with which to smite an EID, vulnerabilities may stem from these very advantages. There is more travel, trade and tourism in developed countries for example, all of which increase the chance of cross-infection. Then there is demography. Susan Peterson has argued that countries such as China and India have large populations that could more easily cushion a huge death toll from an EID. Conversely then, the same proportion of deaths per thousand occurring in Europe, where birth rates are already below replacement level, could be devastating.

Wealthier societies are psychologically less prepared for large-scale deaths from disease within their population: it follows that the trauma and economic shock could possibly then be greater. Panic and suspicion would grow as every citizen became a potential biological bomb. Confidence in the government’s custodial function would erode and could provoke a crisis of legitimacy for the power structure. People would retreat into a survivalist mindset and could begin to see the government as the visible manifestation of an invisible enemy. Good information may do little to mitigate the situation. A study conducted in Canada during the SARS outbreak found that just exposing people to large amounts of information about the disease was not enough to strengthen their knowledge, nor to convince them to change their behaviour.

Increasing numbers of bio-research programmes in developed countries carry the risk of more accidental infections or security leaks. Some fear that experiments carried out in the US for example, with agents such as smallpox, could make the use of smallpox in bioterrorism more likely.

The particular properties of EIDs make them a hot candidate for securitisation. They are transnational/ global in reach; they are deadly; their epidemics create a massive economic impact; they are fiendishly difficult to stop, if not impossible; they have a ‘value-added’ aspect of creating terror and suspicion in affected populations; epidemics could rage for up to three years; solutions to a full epidemic would have to be drastic and unpopular.

Policies for government co-operation on non-military threats remain underdeveloped and this needs to change. The government needs to be able, in a disease emergency, to marshal the resources of the state – public and private – towards fighting the viral enemy. It may be required to impose unpopular decisions on its people, including quarantine, travel restrictions, shortages of goods, a ban on large public gatherings, compulsory vaccinations and the like.

Death tolls could be massive from H5N1. The economic impact from SARS, Michael Osterholm writes, offers a foretaste of what we might expect from an explosion of a new influenza. A global ‘bird flu’ pandemic would put almost every country in a protracted state of siege. Surviving this state requires detailed planning – including stockpiling of vaccines, medicine, fuel, even food – and deep co-operation with the private sector.

In assault by a non-military threat, private businesses have a huge role to play – indeed their co-operation is essential. The private sector manufactures all vaccines, for example, produces and distributes food, fuel and medical equipment etc. A disruption of these services could not be replaced by government bodies, and nor should they be. Agreements should be made beforehand with key businesses, and the private sector involved in emergency planning. While national security is potentially the issue, the same restrictions of intelligence and clearance will not be applicable in the same degree that they are when the national security issue is a human aggressor.

Planning could begin with the production of large amounts of anti virals, very likely an effective weapon in the battle against influenza. Vaccine production would most likely have to wait until the epidemic had actually begun as the particular strain of ‘flu would first have to be isolated (although there are rumours that a vaccine that works on H5N1 has been developed). ‘Sleeper’ factories could be designated, ready to go into mass production once the vaccine had been created. This would probably make more sense than nationalising existing factories. There aren’t currently enough anyway. In the US , the Bioshield Law is admirably trying to provide incentives to private firms to invest in such measures. However, as Michael Osterholm points out, it is of limited because it does not address international needs.

There is possibly another ‘fatal flaw’ in the Bioshield law. Although it does make specific mention of antivirals, development of vaccines will be guided by the Secretary of the Department of Homeland Security. Their mandate is to monitor on an ongoing basis the Chemical, Biological, Radiological and Nuclear (CBRN) agents that present a material threat to the US for which countermeasures are needed. This appears to focus on intentional infections by terrorists or rogue states. This could cause the department to focus on the wrong infections. Far more dangerous — and far more likely – is a naturally occurring epidemic of deadly influenza. As Osterholm goes on to suggest, we need a vaccine that works on all influenza sub-types and that can be distributed to the whole world. If this has been developed, production and plans for distribution ought to be going into high gear.

It is difficult to imagine the scenario being discussed in the absence of a real pandemic, but it could change the world almost overnight. Populations in Western countries would not be quarantined from the effects, as they are to a large extent from the everyday realities of the war in Iraq for instance. There would be nothing to see on television, only emptying public spaces and growing numbers listing the dead. The globalised planet would temporarily shut down and retreat back into fortress nation states. Immigration, travel and trade would have to all but cease, at least temporarily.

The problem is real, it’s big, and it has the potential to threaten the survival of sovereign states. This does not mean that every aspect of an epidemic needs to be under the sole control of the military. Disease remains primarily a public health issue, associated with the domestic sphere and with keeping people alive, while security is usually related to the military sphere and aggression. The inherent opposition between the domestic and the military has to be reconciled if we want practical solutions. The ethical questions – on quarantine, triage, vaccine allocation, for example – will cause deep divides and it is important to have those debates now, before a pandemic begins and fear and a ‘ticking bomb skew our collective thinking.

Personal liberties will again be in the front trenches – as they are today in debates on terrorism prevention — but in an even more immediate and more intimate position. The need for a blanket approach – for total co-ordination of military, local and federal government, the private sector, as well as of global efforts – is far more relevant to disease than it is even to anti-terrorism measures. Submission to disease is not an act of malicious intent; how then do we deal with the infected? How would our social capital stand up to the strain of an indiscriminate and invisible invader with a potential for devastation that could out-do the most disgruntled human powder-keg? Nation states need very visible, very practical and very well-explained procedures to counteract the social and economic fall-out of the organisms themselves, which could be just as damaging to our national fabric.

Talk of powder kegs in this context brings up the issue of biological terrorism – on our population or our livestock — which is a separate, but related, issue. It is perhaps an unwise exercise in hubris to point it out, but to date bio-terror attempts have been largely unsuccessful. Aum Shinrikyo is the only terrorist group to have used biological toxins and human pathogens in an attempt to cause mass murder, and it took them eight attempts. This points to the difficulty of developing these capabilities, even with funds and scientific knowledge. What exactly is the threat? Although any toxin or infectious agent could in theory be weaponised, the WHO believes that there are only five diseases likely to be used in a biological weapon: anthrax, botulism, small pox, plague and tularaemia. Person-to-person transmission – and therefore pandemic risk – is only a significant problem with smallpox and plague. This presumably would limit the effectiveness of an attack with the remaining three pathogens to the immediate area. The intersection with traditional security concerns in this case is clear.

Today, the greatest threat of pandemic yet to appear in modern times is on the horizon. Avian Influenza, H5N1, ‘Bird Flu’ is flashing early warning signs like lightning in a distant storm cloud. The WHO global pandemic threat level is at three on a scale of six. They are considering raising it to four, even five due to disturbing new evidence of mutated H5N1 in ducks, and possibly in pigs in the form of streptococcus suis outbreaks in China. A rise to level four means the deployment of international stockpiles of antiviral drugs and could see countries restricting travel to certain areas. Outbreaks in Novosibirsk in Russia and Kazakhstan , as well as Vietnam , China , Indonesia . . . show it is creeping west as well as south.

The first step is to realise the threat to national security that can exist in a naturally-occurring epidemic, and to understand the necessity of being able to present a wholly integrated national (and then transnational) plan to combat it. The second is to prepare to wage total war on our own soil, to harness all resources, public and private, and to ensure other countries are doing likewise. A worldwide pandemic will be the true test of just how co-ordinated and integrated and resilient our globalised world is. Lets just hope the pustules and plage pits remain where they are, well behind us.

Miranda Darling is an Adjunct Scholar at The Centre for Independent Studies.