Prevent, Detect, Respond: Understanding Security and Global Health

Prevent, Detect, Respond: Understanding Security and Global Health

A One Week Intensive Global Health Policy Course in Geneva, Switzerland, from June 26-30th, 2017

Background

The adage of ‘prevent, detect, respond’ remains the key frame for global health security, but how pertinent is this frame for broader health and human security initiatives? This course will examine the multiple levels of health security, examining how these issues can be linked at the global level (global health security), the national level (national security), and the individual level (human security).

The Course Director is Dr Gavin Yamey, who directs The Center for Policy Impact in Global Health at Duke University ( This year, he is being joined by Dr Clare Wenham of the London School of Economics and Political Science, Department of Health and Social Care ( This is Clare’s first year teaching on this course.Our teaching assistant is Jamal Edwards, a graduate of the Duke Geneva Global Health Fellows program, who is currently at Stanford studying for a Masters in International Policy Studies (

Security from What? Security for Whom?

Outbreaks of SARS, Ebola and Zika have reframed how disease is understood both within the global health policy landscape and by political actors. Tensions remain between prioritizing the best public health response to outbreaks of disease for individuals affected and ensuring broader political and socio-economic stability. The course will explore these tensions and how best we can respond to them through epidemic preparedness and wider health system strengthening.

▪ Global health security. Global health security has become a set of buzzwords amongst political leaders, but what does this term mean? This connection between health and security recognizes that in our interconnected world a disease outbreak in one country can pose a threat to the global population. As such, to combat the potential risks, ensuring global health security requires global collective action. Such action includes fostering epidemic preparedness, sharing of data on outbreaks and their underlying pathogens, and global responsibility to tackling global challenges such as antimicrobial resistance and counterfeit and sub-standard anti-microbial drugs.

Furthermore, global health security can be challenged by inadequate investment in public health, environmental change, biosecurity hazards, and unsuitable animal husbandry practices. By highlighting the collective risks posed by health to the global population, global health security requires proactive and reactive activities to minimize mutual vulnerability to public health threats to populations living across geographical boundaries.[1]These activities often include a focus on prevention, detection and response to health concerns, as highlighted by the International Health Regulations (2005).[2]

However, there are inherent flaws with understanding security in collective terms, and it often leads to problems of accountability with multiple actors with competing agendas.[3]There are also debates as to “what is in and what is out” when it comes to collective security. For example, while the term global health security usually refers to infectious disease threats, risk factors that cause non-communicable diseases also “cross national borders and affect collective health security.”[4] Globalization and associated trade have been associated with the spread of risks such as smoking and the consumption of energy-dense processed food, prompting national, regional, and international collective action (e.g. as seen with the Framework Convention on Tobacco Control or the IMF’s provision of technical assistance to low and middle income countries on tobacco tax policy).

▪ National security. This connection between health and security considers the state as the focus of the potential threats. A social contract between a population and its government ensures that individuals give up some of their freedom in exchange for provision of health (in some instances) and a protection from threats such as disease. Often this framing of security and health can be seen through a focus on economic and diplomatic power, on militaries, and a binary division between security and insecurity. This framing can consider the health of a military force (such as cholera outbreaks in barracks, or HIV prevalence amongst populations) but more recently it is apparent that several governments have pandemic disease in their national security strategies.[5]

Ultimately, the aim of ensuring national security is social and economic stability and the longevity of the state. This stability and longevity can be threatened by health crises, migration trends, bioterrorism, and social disruption caused by pandemics—and thefear of pandemics. Most of the economic losses associated with outbreaks (e.g. the US$ 2.8 billion loss from Ebola across Guinea, Liberia, and Sierra Leone) are from indirect effects: (i) reduction in the labor force due to illness and death, and (ii) behavior changes induced by fear (e.g., closure of businesses and schools, health system collapse, reduction in tourism and trade).[6]

▪ Human security. Understanding the connection between security and health from a human security perspective puts the individual and human rights at the center of analysis. As Ogata and Sen have argued: ‘Human security is concerned with safeguarding and expanding people’s vital freedoms. It requires both shielding people from acute threats and empowering people to take charge of their own lives.’[7]

This framing shifts the security focus from the state or global population to individuals at risk of disease or ill health. It considers the changes posed by globalization that a state can no longer mediate between the individual and global forces and is highly connected to movements for international development and the improvement of quality of human life. Often it considers two key factors as ‘freedom from want’ (quality of life, freedom from poverty) and ‘freedom from fear’ (and the social contract between the state and population).[8]But human security is often used as a slogan, with little commitment to it in practice, despite considerable rhetoric by policymakers[9].

Each of these three framings of health security will manifest in different policy options. This course will examine these range of framings of health and discuss the policies that develop as a consequence. Moreover, it will consider the focus on epidemic preparedness and ‘prevent, detect, respond’ and explore whether this remains the most suitable emphasis for ensuring health for the global population.

Structure of the Course

The course involves seminars, panel discussions, site visits, a policy case competition, and mentorship meals (one dinner, one lunch).

  • Seminars and panel discussions: these will be led by internationally renowned experts from the WHO and other Geneva-based organizations, including several WHO Directors (e.g. Shekhar Saxena, Director of the Department of Mental Health and Substance Abuse (MSD) at WHO's Headquarters Office).
  • Site visits: we will visit tbc influential organizations that represent a variety of sectors (e.g. inter-governmental, civil society, product development public-private partnerships)
  • Policy case competition (a collaboration with the Humanitarian Action Fellows track): For this competition, you will work in 4 teams made up of Fellows from both the Global Health and Humanitarian Action tracks. The competition will involve developing a vaccination policy for refugee settings. Further details will be provided in a separate guidance document.
  • Mentorship meals: these are informal opportunities (a dinner and a lunch), away from the campus, to discuss careers with the course directors.
  • Office hours: you will all have the opportunity to meet one-on-one with Gavin, Clare, and Jamal for individual advice.
  • Reflections: we have built in some opportunities in the week for us to reflect as a group on the learnings.

The course is structured in this way to give participants an appreciation of the contextual factors influencing global health and the policy levers that we can use to transform global health status going forward. As part of Duke University’s Geneva Program on Global Policy and Governance, the course is designed to complement the policy internship at a major international organization completed by every Global Health Fellow.

Readings

The readings below are meant to serve as starter resources. For each session and site visit, we have carefully picked about 5 key readings. They hopefully will enrich your understanding of the context of the seminar, panel, or site visit discussions. If you want to dig deeper into global health policy, you will find detailed analyses of many of the core themes of the course in The Handbook of Global Health Policy, edited by Brown WG, Yamey G, and Wamala S (Oxford, UK: Wiley-Blackwell, 2014, at The introductory chapter gives a helpful overview of the book. A PDF of this chapter will be provided to you, as will the chapters related to security, i.e. chapters 15-18:

  • Arguments for Securitizing Global Health Priorities, by Simon Rushton
  • Viral Sovereignty: The Downside Risks of Securitizing Infectious Disease, by Stefan Elbe and Nadine Voelkner
  • The Humanitarian Sector in Evolution: Repercussions for the Health Sector, by François Grünewald and Veronique de Geoffroy
  • The Limits of Humanitarian Action, by Hugo Slim

These four additional papers will help give you a good grounding in the overarching, cross-cutting themes of the course:

  • Pibulsonggram N, Amorim C, Douste-Blazy P, et al. Oslo Ministerial Declaration–global health: a pressing foreign policy issue of our time. Lancet 2007;369(9570), 1373-8.
  • Gostin LO, Mok EA. Grand challenges in global health governance. British Medical Bulletin2009;90(1):7-18. At
  • Heymann DL, Chen, L, Takemi K, et al. Global health security: the wider lessons from the west African Ebola virus disease epidemic. Lancet2015; 385(9980), 1884-1901.
  • Schäferhoff M, Suzuki E, Angelides P, Hoffman SJ (2015). Rethinking the global health system. Chatham House Research Paper. At

2. SEMINARS AND PANEL DISCUSSIONS

Session 1: Health Security: Where Are We Now?

  • How has the connection between health and security developed over recent decades?
  • What are the key strengths and limitations of connecting health and security
  • How can using the security agenda distort health priorities, and how can we mitigate against this?
  • Does connecting security and health reflect foreign policy interests?

Required reading

  • Rushton S. Global health security: security for whom? Security from what? Political Studies 2011;59(4):779-796
  • McInnes C, Lee K. Health, security and foreign policy. Review of International Studies 2006;32(01):5-23.
  • Davies S. Securitizing infectious disease.International Affairs2008;84:295-313
  • Aldis W. Health security as a public health concept. Health Policy and Planning2008;23: 369 – 375
  • World Health Organization. (2007). The World Health Report 2007. A Safer Future: Global Public Health Security in the 21st Century. At

Session 2: Human Security: Finishing the Unfinished Agenda of Maternal and Child Health

  • What does the burden of maternal and child health tell us about global health priorities in a securitized world? Why is maternal and child health left out of security discussions?
  • SDG 3 calls for the global maternal mortality ratio to reach less than 70 per 100,000 live births and “an end” to avertable child and newborn deaths by 2030. Are these targets feasible and how would we get there? Can a security framing help us meet this target?
  • What are the specific health needs of women and children in refugee and other complex humanitarian emergency settings?
  • What are the key innovations in R&D, delivery, financing, and policy that will be needed to finish the unfinished agenda of maternal and child health?

Required reading

  • Bustreo S, Zaid S. Leave no one behind: Women, children and adolescent health in emergencies. Devex, May 10, 2016.
  • Kuruvilla S, Bustreo F, Kuo T, et al. The global strategy for women's, children's and adolescents' health (2016-2030): a roadmap based on evidence and country experience. Bull World Health Organ. 2016;94:398-400
  • Stenberg K, Axelson H, Sheehan P, et al. Advancing social and economic development by investing in women’s and children’s health: a new Global Investment Framework Lancet 2014; 383:1333-54
  • Engmann CM, Khan S, Moyer CA, Coffey PS, Bhutta ZA. Transformative innovations in reproductive, maternal, newborn, and child health over the next 20 years. PLoS Med 2016;13(3): e1001969
  • McDougall L, Sharma A, Franz-Vasdeki J, et al. Prioritising women's, children's, and adolescents' health in the post-2015 world. BMJ 2015;351:h4327.

Session 3: Global Health Security: Universal Health Coverage (UHC), Health Systems Strengthening (HSS), and Resilience

  • How is UHC defined and how will progress towards UHC be measured?What are the major policy challenges in implementing UHC and how can these be overcome?
  • How can UHC help to strengthen global health security? What are the linkages between UHC, security, HSS, and resilience?
  • Ensuring global health security requires financial commitment to strengthen domestic surveillance and response mechanisms, as well as broader provision of health services. This domestic need has often been forgotten in the WHO and Global Health Security Initiative ( rhetoric. Where will the funding come from?
  • What is the role of international donors in financing global health security, and how can such funding be made sustainable? How realistic is it to expect LICs and MICs to fund their own domestic surveillance and response mechanisms? Are there innovative domestic sources of health financing? What is the role of the World Bank Pandemic Insurance Fund and the WHO Contingency Fund for Emergencies?

Required reading

  • Kutzkin J, Sparkes SP. Health systems strengthening, universal health coverage, health security and resilience. Bulletin of the WHO 2016;94:2. At
  • Jain V, Alam A. Redefining universal health coverage in the age of global health security. BMJ Global Health 2017;2(2): e000255. At
  • Sands P, Mundaca-Shah, Dzau V. The neglected dimension of global security — a framework for countering infectious-disease crises. New Engl J Med 2016; 374:1281-1287
  • Frenk J, deFerranti D. Universal health coverage: good health, good economics. Lancet 2012; 380: 862-864
  • Røttingen J-A, et al. Shared Responsibilities for Health: A Coherent Global Framework for Health Financing: Final Report of the Centre on Global Health Security Working Group on Health Financing. At
  • Kruk, M. Universal health coverage—a policy whose time has come. BMJ 2013; 347: f6360.

Session 4: Global, National, andHuman Security: R&D for Health Development

  • What is the role of research and development (R&D) in improving global health? How do such improvements help boost human, national, and global security?
  • How important are technological innovations when it comes to tackling emerging infectious diseases with epidemic or pandemic potential?
  • When the Ebola epidemic struck West Africa, why was there no Ebola rapid diagnostic test, treatment, or vaccine ready for use?
  • What are the biggest challenges to sustained financing for R&D for epidemic/pandemic preparedness?
  • How do funding priorities affect R&D?
  • How are the new Coalition for Epidemic Preparedness Innovations(CEPI, at and the WHO R&D Blueprint for Action to Prevent Epidemics ( helping to address R&D gaps?

Required reading

  • Balasegaram M, Bréchot C, Farrar J, Heymann D, Ganguly N, Khor M, et al. A global biomedical R&D fund and mechanism for innovations of public health importance. PLoS Med 2015;12(5): e1001831
  • Overview of CEPI:
  • Kieny MP, Røttingen J-A, Farrar J. The need for global R&D coordination for infectious diseases with epidemic potential. Lancet 2016;388: 460-461
  • WHO R&D Blueprint
  • Elbe S. The pharmaceuticalisation of security: Molecular biomedicine, antiviral stockpiles, and global health security. Rev Int Stud. 2014 Dec;40(5):919-938. At

Session 5: Mid-Week Course Reflections

In this session, the course directors and TA will lead a group reflection on the learnings from the first half of the course.

Session 6: Human Security: Meeting the Challenge of Global Mental Health

  • What is the global burden of mental health disorders and how can the human security agenda increase awareness of this burden?
  • Where are the treatment gaps and how can these be closed, particularly in low-resource settings? What role does stigma play in preventing treatment access and how can this be tackled?
  • What are the national, regional, and international policy levers that can help improve mental health worldwide?

Required reading

  • Patel V, Boyce N, Collins PY, Saxena S, Horton R. A renewed agenda for global mental health. Lancet 2011; 1441–1442.
  • Patel V, Saxena S. Transforming lives, enhancing communities—innovations in global mental health. N Engl J Med 2014; 370:498–501.
  • Patel V, Chisholm D, Parikh R, et al, on behalf of the DCP MNS Author Group. Addressing the burden of mental, neurological, and substance use disorders: key messages from Disease Control Priorities, 3rd edition. Lancet 2016; 387: 1672-85
  • Saxena S, Funk M, Chisholm D. World Health Assembly adopts Comprehensive Mental Health Action Plan 2013–2020. Lancet 2013; 381:1970–71.
  • Collins PY, Insel TR, Chockalingam A, Daar A, Maddox YT. Grand challenges in global mental health: integration in research, policy, and practice. PLoS Med2013;10(4): e1001434.

Session 7: The Governance of Global Health Security. A Case Study of the Ebola Outbreak

  • What are the features and characteristics of our current global health governance system?
  • How do we define governance for global health security and how/why has it evolved since the early days of international health cooperation?
  • What are the major governance challenges and how are they impeding the effectiveness and efficiency of the global health ‘system’?
  • What are the key weaknesses in the global governance system for health security? How did the Ebola epidemic expose these?
  • How can this system be strengthened so that it is ready to tackle the next major outbreak?

Required reading

Moon S, et al. Post-Ebola reforms: ample analysis, inadequate action. BMJ2017;356:j280

  • Moon S, et al. Will Ebola change the game? Ten essential reforms before the next pandemic. The report of the Harvard-LSHTM Independent Panel on the Global Response to Ebola. Lancet 2015;386:2204-2221.
  • Fidler DP. The challenges of global health governance. Council on Foreign Relations Working Paper, 2010. At
  • Evans TG. Governance for global and national health—a role for framework conventions? Health and Human Rights 2013, at
  • Frenk J, Moon S. Governance challenges in global health. New England Journal of Medicine 2013;368(10):936-942.
  • Sridhar D, et al. Facing forward after Ebola: questions for the next director general of the World Health Organization. BMJ2016;353:i2666
  • Gostin L, Friedman E. Ebola: a crisis in global health leadership. Lancet 2014; 384:1323-5.

Session 8 Global & National Health Security: The Global Threat of Antimicrobial Resistance & Switzerland's National Response