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Abstract
This paper analyses the mechanisms through which experts in the field of global health work to manage the future well-being of populations. It develops a contrast between two ways of approaching disease threats: actuarial and sentinel devices. If actuarial devices seek to map disease over time and across populations in order to gauge and mitigate risk, sentinel devices treat unprecedented diseases that cannot be mapped over time, but can only be anticipated and prepared for. The paper shows that a recent controversy over vaccination in Europe in response to the H1N1 pandemic can be understood in terms of the tension between these two kinds of security mechanisms.
Disclosure statement
No potential conflict of interest was reported by the author.
Notes
1 As he writes at the outset of the third lecture, ‘This year my plan was to bring out what is specific, particular, or different in the apparatuses of security when we compare them with the mechanisms of discipline I have tried to identify’ (Foucault, Citation2007, p. 55).
2 ‘I think the integration of the town within central mechanisms of power, or better, the inversion that made the town the primary problem, even before the problem of the territory, is a phenomenon, a reversal, typical of what took place between the seventeenth and the beginning of the eighteenth century. It was a problem to which it really was necessary to respond with new mechanisms of power whose form is no doubt found in what I call mechanisms of security’ (Foucault, Citation2007, p. 64).
3 Hacking (Citation1990, p. viii) calls this process ‘the avalanche of printed numbers’.
4 Niklas Luhmann (Citation1998, p. 70) describes the relation between present decision, based on risk calculation, and potential future responsibility: ‘the present can calculate a future that can always turn out otherwise; so the present can assure itself that it calculated correctly, even if things turn out differently’.
5 See ‘Farr's biometer: The life table and its applications in medicine and economics’, in Eyler (Citation1979).
6 See ‘Inequality before death: Paris’, in Coleman (Citation1982). See also Rabinow (Citation1989).
7 Important contributions to the growing literature on the question of the limits of actuarial rationality in dealing with catastrophic events include Bougen (Citation2003), Ericson and Doyle (Citation2004) and Collier (Citation2008).
8 The first US cases of A/H1N1 were detected in April 2009 by a naval disease surveillance project supported by the US Armed Forces Health Surveillance Center's Global Emerging Infections Surveillance and Response System (AFHSC-GEIS), a sentinel device for detecting the emergence of novel pathogens. A report from the AFHSC notes: ‘By supporting global surveillance and supporting local response efforts, DoD serves as a sentinel for local epidemics and can assist in limiting disease transmission’ (Burke, Citation2011, p. 2).
9 For a discussion of the controversy that arose around inequitable global access to the H1N1 vaccine, see Fidler (Citation2010).
10 The co-author of this paper, Harvey Fineberg, had also co-authored a book on the 1976 swine flu ‘fiasco’ that diagnosed US health officials' failure to respond flexibly to an uncertain event (Lakoff, Citation2008). In 2010, he was named the chair of the committee charged with investigating the WHO's (Citation2009) response to H1N1 under the aegis of the IHR.
11 The prioritization scheme was the product of long-term preparedness planning, oriented towards the goal of protecting the functioning of ‘critical infrastructures’ during a health emergency.
12 Based on fieldwork at the US CDC, anthropologist Theresa MacPhail (Citation2010) argues that ‘strategic uncertainty’ was used to maintain scientific and public health authority throughout the H1N1 episode.
13 Of course, had the strain proven more virulent, a very different scandal might have arisen around the question of unequal access to medical counter-measures in the event of pandemic emergency.
14 Frédéric Keck suggests that the French government was constrained in its response to H1N1 by a framework of ‘precaution’ – as opposed to preparedness, which might have implied a more flexible and less immediately intensive response (Mongin & Padis, Citation2011).
15 The volume came out of a 1989 meeting co-organized by Stephen Morse and Nobel prize-winning biologist Joshua Lederberg.
16 It should be noted that the alert system was specific to pandemic influenza, and did not apply to other IHR events. And while all IHR signatories were bound to respond to a WHO PHEIC, not all member states had adopted the pandemic alert system.
17 The IHR Review Committee agreed with this assessment: ‘The response to the emergence of pandemic influenza A (H1N1) was the result of a decade of pandemic planning, largely centred on the threat of an influenza A (H5N1) pandemic’ (WHO, Citation2011, p. 10).
18 Intriguingly, this was the same conclusion that the Review Committee chair, Harvey Fineberg, had reached in his co-authored book evaluating the much-criticized US CDC response to swine flu in 1976 (Neustadt & Fineberg, Citation1983).
Additional information
Notes on contributors
Andrew Lakoff
Andrew Lakoff is an Associate Professor of Sociology at the University of Southern California. He is the author of Pharmaceutical reason: Knowledge and value in global psychiatry (Cambridge, 2006), and co-editor, with Stephen J. Collier, of Biosecurity interventions: Global health and security in question (Columbia, 2008).