Securing Indo-Pacific health security: Australia’s approach to regional health security

ABSTRACT

In the wake of several prominent disease outbreaks like Ebola and Zika, global health security is once again high on the international agenda. For its part, the Australian government has committed itself to strengthening regional health security. This policy direction – focusing on the Indo-Pacific region – is both consistent with Australia’s traditional foreign policy approach of concentric circles informing strategic priorities, and is therefore understandable, even predictable. But given that local disease outbreaks in remote locations around the world now have the opportunity to travel rapidly internationally, is the adoption of an exclusively regional focus the most sensible one? This article considers the implications of Australia’s new regional health security initiative, its focus and direction. The paper weighs the benefits and drawbacks of Australia’s new programme and considers whether a wider focus is more appropriate for responding to the health threats of the twenty-first century.

KEYWORDS:

• Global health security
• Indo-Pacific
• regional security
• disease outbreaks

Introduction

On 8 October 2017, Australia’s then foreign minister, the Hon. Julie Bishop, officially launched the Australian Government’s new regional health security initiative (Bishop 2017a). The government’s five-year commitment entails a total allocation of $300 million, which represents a tripling of the Liberal and National Parties’ (the Coalition) September 2016 election commitment of $100 million towards strengthening regional health security. Central to the government’s programme is the creation of a new Indo-Pacific Centre for Health Security, a $75 million fund to support product development for medical treatments and diagnostics, a $16 million fund for new collaborative research around a sub-set of regional low-income countries to strengthen health systems, and $26 million towards the World Health Organization’s new Health Emergencies Programme (WHE). This new initiative represents the latest iteration of the Australian Government’s efforts to strengthen regional pandemic preparedness that was initiated in 2005 under John Howard’s government in the form of the Asia-Pacific Strategy for Emerging Infectious Diseases (APSED) and related initiatives (Kamradt-Scott 2009), but it represents a sizeable increase over previous investments.

Commensurate with the escalation of funding has been a notable change in rhetoric. No longer do the official announcements and associated documents refer to the ‘Asia-Pacific’; rather, consistent with the policy shift initiated under former Prime Minister Julia Gillard’s administration, Australia’s region of influence is now described as the ‘Indo-Pacific’. As Medcalf (2014) has noted, this shift in terminology has been the subject of much debate, even controversy, as some have interpreted it as an attempt to obfuscate East and Southeast Asia generally, and China’s growing influence in the region specifically. Irrespective of the descriptor used though, or whether countries previously ignored by the ‘Asia-Pacific’ have now been incorporated, the government’s focus remains fixatedly informed by the ‘concentric circles’ approach to foreign and defence policy – a strategy that, importantly, was adopted in the mid-1980s but which has since been repeatedly described as outdated given the challenges associated with globalisation (Lyon and Tow 2005; Aysson 2007; Wesley 2016).

In addition, the Australian Government has purposefully chosen to frame this new initiative in terms of regional ‘health security’. While this is consistent with a wider international policy direction promoting ‘global health security’, several countries within the Indo-Pacific region previously openly opposed the use of the phrase ‘health security’ in describing public health-related activities. Indeed, between 2007 and 2014 countries including Thailand, Indonesia and India expressed strong reservations about the conflation of public health issues with security language, concepts and terminology. At the heart of these concerns was the lack of consensus around what ‘health security’ meant, the scope of issues it applies to, and a perception that it is fundamentally about high-income countries protecting themselves from diseases arising elsewhere. In part due to the opposition voiced by these countries and others, the World Health Organization (WHO) backed away from using ‘health security’ in policy-related documents (Kamradt-Scott 2015). Although in the wake of the 2014–2016 West African Ebola outbreak governments are once again talking about the urgent need to strengthen global health security, it remains to be seen how the Australian Government’s explicit focus on regional health security will be viewed by those countries Australia seeks to assist.

The aim of this paper is to examine the benefits and drawbacks of the new regional health security initiative, and whether a programme explicitly focused on the ‘Indo-Pacific’ region is entirely fit-for-purpose. The article commences with briefly reviewing the Australian Government’s efforts in strengthening regional pandemic preparedness before considering how much a focus on the immediate Indo-Pacific region is appropriate in a highly interconnected world. From here, the discussion considers the risks and benefits of framing public health issues using the ‘health security’ concept and language, and how this has been received by key governments and other regional actors. The paper concludes by reflecting on what this initiative purports to offer the region – and Australia – given the fault lines surrounding ‘global health security’, and what the government’s regional health security initiative signals for the immediate future.

From ‘regional preparedness’ to ‘regional health security’

The Australian Government maintains a strong interest in the health affairs of Indo-Pacific countries. With a combined population comprising two-thirds of the entire world, extensive urbanisation, intensive animal farming practices, huge variation in health system capacity within and between countries, a history of public health events that have included novel pathogens, and the progressive spread of antimicrobial resistance, the Indo-Pacific region has understandably attracted the reputation as serving as both an ‘epicentre’ and ‘hotbed’ of infectious diseases (Bordier and Roger 2013, 42; Kang and Song 2013; Schierhout, Gleeson, Craig et al. 2017, 1; Wenham 2018). In this context, Australia’s extensive international travel and trade arrangements with the region may be viewed by some as hazardous, potentially jeopardising the health, wellbeing and security of Australia’s population (Byrne 2015); but it can equally be viewed as offering a valuable opportunity for Australia to assist its neighbours in extending technical assistance, thereby increasing Australia’s ability to exert soft power and influence throughout the region. Arguably, both of these narratives were at play within the Australian Government at the start of the new millennium.

The 2003 Severe Acute Respiratory Syndrome (SARS) outbreak which was soon followed by the emergence and dissemination of H5N1 avian influenza throughout Asia the same year generated significant alarm around the world. For many in global health, the SARS outbreak was viewed as a very timely ‘wake-up call’ that revealed how easily novel pathogens could rapidly spread via international air travel around the world. Followed, as it was, by the progressive spread of H5N1 which raised the prospect that another influenza pandemic was imminent, by early 2006 considerable diplomatic pressure had been brought to bear on the menace posed by infectious diseases. As a result, multiple high-level meetings were held, new financial commitments were made, strategic documents were developed, adopted and released, and the global health community came together to finalise the revision process of the International Health Regulations in May 2005.

For its part, the Australian Government – led by then Prime Minister John Howard – placed a heightened emphasis on strengthening pandemic influenza preparedness (PIP), both at home and abroad. Of the government’s overall AUD$599 million PIP spending package that was announced between 2003 and 2008, some $141 million was designated to assist neighbouring countries strengthen their preparedness and a further $44 million to preventing H5N1 entering Australia (DoHA 2008). In addition, through a publication of the now-defunct Australian overseas development agency AusAID (2006, 7), the Australian Government specified that its priorities for mitigating the human health and economic impacts from emerging infectious diseases during the period 2006–2010 included:

• to develop effective capacity to plan and prepare for emerging infectious diseases (EIDs) and potential pandemics;

• to improve the recognition, control and prevention of EIDs;

• to strengthen national systems of animal and human health; and

• to facilitate a rapid response to outbreaks of EIDs in animals and/or humans.

As part of this new strategy and its associated funding, the Australian Government launched an extensive bilateral and multilateral programme that was designed to assist Asia-Pacific countries enhance their preparedness. Specifically, the government sought to provide direct assistance to countries that included Indonesia, Papua New Guinea, Timor-Leste, Philippines, Vietnam, Lao PDR, Cambodia, Burma, China, and the Democratic People’s Republic of Korea on a bilateral basis with the majority funds allocated to those in closest proximity (see, for example, Commonwealth of Australia 2010). Importantly, however, Australia also actively supported various multilateral institutions extending from the WHO (including its regional office for the Western Pacific or WPRO), the World Bank, the World Organization for Animal Health (OIE), and the Food and Agriculture Organization (FAO) through to the Asia-Pacific Economic Cooperation (APEC), Association of South East Asian Nations (ASEAN) and the Secretariat of the Pacific Community (SPC) (AusAID 2010; Schierhout, Gleeson, Craig et al. 2017).

To coincide with the AusAID strategy, the Australian Government also strongly supported the creation of the Asia-Pacific Strategy for Emerging Infectious Diseases 2006-2010 (APSED I). As Davies (forthcoming) has noted, the creation of APSED was a novel, forward-thinking initiative that sought to overcome historically artificial, WHO-generated structural divisions within the region, namely the existence of two distinct regional offices, to ‘coordinate communication and engagement across two regions that were geographically linked by structural separation under the WHO management framework’. The outcome was that both the WHO’s South East Asian regional office – SEARO – and the Western Pacific Regional Office (WPRO) endorsed the strategy in September 2005 (WHO 2010). Australia’s support for APSED under a now-Labor Government led by Prime Minister Kevin Rudd was renewed in 2010 for another five-year period (APSED II), culminating in a further investment of AUD$28.8 million (Schierhout, Gleeson, Craig, et al. 2017); but it also has to be acknowledged the Australian Government’s interest in the second phase of APSED lessened, due in part to a period of intense domestic political turmoil that resulted in, amongst other things, the absorption of AusAID into the broader Department of Foreign Affairs and Trade (Corbett and Dinnen 2016; Davies forthcoming).

In 2017 the Australian Government again made international headlines following Julie Bishop’s announcement of a new AUD$300 million commitment to strengthening regional health security (Cornish 2017). The Australian foreign minister’s proclamation followed the appointment of a new Ambassador for Regional Health Security, Mr Blair Exell (Bishop 2017b). Australia also accepted to serve as co-chair of the Joint External Evaluation (JEE) Alliance that was committed to assisting countries meet their obligations under the International Health Regulations (2005) (IHR 2005) by strengthening core capacities to detect, prevent, and control public health emergencies of international concern (JEE Alliance 2017). These various announcements took many within the Australian public health and development communities by surprise, principally due to the previous reductions in Australia’s foreign aid budget instituted by Prime Minister Tony Abbott and maintained by the Turnbull Government (Howes 2017). Indeed, for many, these various announcements appeared to emerge without prior warning that Australia’s conservative political leadership held any interest in health-related aid work.

Arguably, several factors contributed to the Australian Government’s renewed interest in regional health matters. The fact that Australia had assumed a prominent financial role in supporting APSED I and II, and there were a number of discussions throughout 2015 and 2016 about the need for APSED III (SEARO-WPRO 2016), fed into internal policy discussions within the Australian Department of Foreign Affairs and Trade (DFAT). Throughout 2015, DFAT held a series of consultations with various stakeholders on the shape Australia’s commitment to APSED III might take. Notably, however, at that point in time the financial contribution the Australian Government was willing to offer was capped at an annual $10 million (DFAT 2015a), in part due to ‘efficiency savings’ and the severe reductions that had been applied to Australia’s foreign aid budget by the conservative Abbott Government. By late 2016, however, several other factors – which notably included the 2014–2016 West African Ebola outbreak and the international spread of Zika – had again raised the importance of regional health to a new level and given it new political prominence.

It is difficult to fully assess the extent to which the 2014–2016 West African Ebola outbreak had a significant impact on the Abbott Government. Given that multiple health groups including the Australian Medical Association, the Public Health Association of Australia, the Australian division of Médecins Sans Frontières, and an open letter from 113 leading public health experts failed to persuade the Coalition to deploy the Australian Medical Assistance (AUSMAT) teams to West Africa (Australian Broadcasting Corporation (ABC) 2014; Uhlmann 2014), it can be reasonably deduced that civil society criticism had little direct influence on government policy. Nor, conspicuously, did criticism from Australia’s government-in-opposition, the Australian Labor Party (Harrison 2015), notwithstanding the fact that while differences do exist, both major political parties traditionally enjoy ‘broad agreement on the component parts’ of Australian foreign policy (Plibersek 2016, 460). Requests for assistance from Australia’s strategic partners, notably the United States and United Kingdom (Cullen 2014), conceivably had more persuasiveness; but even here the Abbott Government obstinately demurred, announcing AUSMAT teams would be kept in Australia on the remote chance Ebola spread to the Indo-Pacific (Nohrstedt and Baekkeskov 2018). At best, therefore, while the West African Ebola outbreak may have registered in the minds of some of Australia’s political leadership, it can only be concluded that it failed to result in decisive, meaningful action. What the West African Ebola outbreak did do, however, was contribute to a narrative: one that emphasised the need for Australia to do more. This was particularly reinforced following the revelation in 2015 that the Zika virus had reappeared in the Pacific Islands.

The first documented cases of Zika outside of Africa had been recorded in the Federated States of Micronesia in 2007. Importantly, however, the virus had seemingly disappeared again from the Pacific until a large cluster of cases was detected in French Polynesia in 2013 and 2014, and subsequent cases emerged in New Caledonia, Easter Island and the Cook Islands (Pettersson, Eldholm, Seligman, et al. 2016; Craig, Butler, Pastore, et al. 2017). This development, combined with the appearance of Zika virus in Latin America ahead of the 2016 Olympics in Rio de Janeiro which was believed to be linked with large number of cases of microcephaly, caused disquiet throughout the world and especially amongst Pacific Island communities. As a result, the Secretariat of the Pacific Community (SPC) was noted to raise their concerns over the spread of Zika with several partners and across multiple fora (see SPC 2016; Tukuitonga 2017).

As one of the key foci of the Australian Government’s aid programme, the concerns of Pacific Island communities – as articulated via the SPC – is likely to have garnered some attention in Canberra. Australia’s willingness to address the concerns of the Pacific Islands has fluctuated markedly over time depending on which of the two major political parties holds government (Schultz 2014). Given that the Australian intelligence, security, and development communities had become increasingly concerned though about the rising influence of new development partners in the Pacific displacing Australia’s influence, specifically the People’s Republic of China (Lanteigne 2012), being seen to help address the spread of Zika in the Pacific aligned with Australia’s doctrine of ‘strategic denial’ of excluding rival powers to retain prominence throughout the region (see Schultz 2014). Being publicly observed to take strong action on the spread of Zika and other regional health ‘threats’ would also likely sit well with the Australian public, in view of the fact anxiety was growing about the virus’ potential spread to Australia (Medew, Miletic, and Flitton 2016). As a result, even before the October 2017 regional health security announcement Julie Bishop had announced an AUD$7.7 million funding package targeting mosquito-borne diseases in Vanuatu, Fiji and Kiribati which included research on preventing the transmission of Zika (Johnson 2017).

Being viewed as a responsible partner willing to assist its regional neighbours also resonated well internationally for a newly-elected Turnbull Government keen to distance itself from its predecessor who was known to eschew foreign affairs (McDonald 2015). Moreover, the new regional health security initiative achieved two further key objectives, the first of which was repairing Australia’s slightly damaged relationship with the United States. In February 2014, the Obama administration had launched the Global Health Security Agenda (GHSA) which provided a strategy for working with partner countries on a range of key health security areas from antimicrobial resistance and food safety, to outbreaks and emergency response (Inglesby and Fischer 2014). Australia partnered early with the GHSA, evidencing its wider international support for the policy shift towards viewing health issues in security terms; but whereas the United States contributed US$1 billion to implement the GHSA ‘packages’ (Michaud, Moss, and Kates 2017), Australia’s involvement in working with partner countries from the region had – until the Foreign Minister’s 2017 announcement – remained largely symbolic, limited to technical assistance. The extent to which this irritated Australia’s key strategic defence partner is unknown. Yet, the Abbott Government’s unwillingness to assume a more prominent role in containing the West African Ebola outbreak did cause tensions, resulting in a highly unusual public criticism of Australia’s position (Kehoe 2014). Despite the November 2016 election of Donald Trump and his persistent undermining of Obama-era initiatives which may yet see the GHSA cancelled (Youde, this issue), the new regional health security initiative would contribute to the perception of Australia being a responsible partner and help soothe any lingering upset.

A further benefit of launching the regional health security initiative was sending a strong signal of Australia’s continued support for global health security. Particularly since 2005, the Australian Government – irrespective of which of the two major political parties was holding office – had repeatedly evinced a predisposition to reframe disease outbreaks as security ‘threats’ (Davies 2008). The government’s involvement in championing the IHR 2005, which even extended to actively shaping the intergovernmental negotiations around the instrument (WPRO 2004; Tucker 2005), further substantiated Australia’s backing of health security given the strong association drawn between the IHR 2005 and global health security (Fidler 2005). This support continued over the next decade, largely uninterrupted by Australia’s revolving political leadership (see, for example, Department of Defence 2009; Chiu et al. 2014); and in January 2015 Australia again displayed its support for global health security in endorsing the creation of the WHO’s new Health Emergencies Programme, or WHE (Executive Board 2015). This very public stance was financially underlined the following year during the 69th World Health Assembly when the Australian Government was one of a small number of early contributors, donating an initial AUD$6 million to the WHE (UN 2016; WHO 2016).

When combined, these multiple factors contributed to the need for Australia to be seen to adopt a stronger role in tackling regional health threats, culminating in the Liberal Party’s 2016 election platform of establishing a $100 million regional health security fund (Liberal Party of Australia 2016). Following the campaign, the newly-elected Coalition Government, in close consultation with DFAT, developed an expanded plan that tripled the Liberal Party’s election promise to such an extent that, at the time of the initiative’s official launch in October 2017, a proportion of the funds remained unallocated. Indeed, at $300 million over five years, the new regional health security initiative represents Australia’s single most generous aid programme for strengthening Indo-Pacific countries’ health systems and outbreak response capacities to ever be launched. The questions yet to be answered, however, are firstly, whether this new initiative is entirely fit-for-purpose, and secondly, whether it is welcomed by those countries Australia seeks to assist. It is to these two issues the paper now turns.

The ‘problem’ with adopting a regional focus

As the 2009 H1N1 influenza pandemic, the 2014 West African Ebola outbreak and pathogens such as the Middle East Respiratory Syndrome (MERS) coronavirus have amply demonstrated, infectious diseases can potentially arise from anywhere to rapidly spread internationally. The first case of the 2009 H1N1 virus to be detected in Australia, for example, was recorded on 9 May 2009, almost four weeks after the first cases were officially reported in the United States (Kelly et al. 2010). By comparison, H1N1 was detected in Hong Kong within a week of the virus being identified in Mexico (Fischer et al. 2011). Although much slower, MERS, which was first identified in 2012 in the Middle East, had spread to over 25 countries throughout Europe, Asia, North America and the Middle East, in six years and resulted in over 1,300 cases (Woo et al. 2018). While no cases of Ebola were imported into Australia during the 2014 outbreak in West Africa, the detection of individuals infected with the virus in the United States, Spain, Italy and the United Kingdom did cause sufficient alarm as to prompt the creation of a dedicated United Nations mission along with multiple bilateral and multilateral offers of support to contain the disease. Put simply, diseases can and do arise from multiple locations and, where the capabilities and means permit, they can be transported to any other terrestrial location within 24–48 hours.

To what extent, therefore, is a government’s exclusively regional focus on infectious diseases appropriate in a highly-interconnected, globalised world? The succinct answer is ‘probably not’; although equally, the Indo-Pacific region may provide a more sound rationale for such investment compared to other regions. As noted earlier, the Indo-Pacific region currently comprises two-thirds of the world’s entire (human) population. The fact that two of the world’s most populous nations – China and India – each with a population well in excess of 1 billion people are co-located within the same geographic area, provides sufficient cause to warrant international attention to the health affairs of the region. In this context, although it has often been observed in respect to economic considerations that ‘When China sneezes, Asia catches a cold’ (Lowther 2013, 36), the same is indubitably accurate with respect to the microbial world as several disease events discussed below attest. Likewise, while antimicrobial resistance in South East Asia has been identified to be a major public health problem, India’s infectious disease burden is amongst the highest in the world, and poor sanitation, malnutrition, and inadequate regulation of the pharmaceutical sector is contributing to the rise of AMR (Kumar et al. 2013).

Added to this, huge variation exists across and within the region not only in terms of economic, political, social and cultural conditions, but also geography, which can have major implications on the shape, style and availability of health system infrastructure and capacities (Chongsuvivatwong et al. 2011). For example, the diversity of economic conditions – from the high-income countries of Australia, Japan and Singapore, to low middle-income countries of Cambodia, Lao PDR and Indonesia – has resulted in considerable variation in access to healthcare, disease burden, and ultimately life expectancy. Similarly, the health and wellbeing of individuals living in small Pacific Island nations varies massively to the large urban populations of Bangkok, Shanghai, and Jakarta, which in turn can differ from highland tribes in Papua New Guinea or the displaced populations of Rohingya in Myanmar and Bangladesh (Aspalter 2006; Lin 2009; Coker et al. 2011). At least with respect to health system capacities and associated health outcomes, therefore, the Indo-Pacific is a region of stark contrasts.

These distinctions have additionally been highlighted in various health crises. During the 2003 SARS outbreak, for instance, whereas Vietnam acted rapidly to isolate and contain suspected cases and thereby avoided a WHO travel advisory, WHO issued travel warnings against other territories with more well-resourced services including Singapore, Taiwan, and Hong Kong due to concerns over their inability to contain the virus (Brookes 2005). In the 2009 H1N1 pandemic, while the region ‘had some weeks lead time’ to prepare for additional cases, the pandemic highlighted several key health challenges extending from effective ‘communication between and within many countries, the differences in levels of funding for health care between countries, access to quality care, health-care worker skills, quality and density and access to essential medicines’ (Fischer et al. 2011, 877). Likewise, the spread of MERS to South Korea and the subsequent outbreak that occurred reinforced once again the experience of Canada during SARS, namely, that even high-income countries with advanced tertiary healthcare systems can struggle to contain a novel pathogen (Cho et al. 2016).

Within this same context, the ‘threat’ spectrum existing within and arising from the region is as equally diverse. Leaving aside the major events of the twentieth century that included the 1957 ‘Asian Flu’ and 1968 ‘Hong Kong Flu’ pandemics, and the emergence of H5N1 ‘Bird Flu’ in 1997 and again in 2003, since the start of the new millennium the region has witnessed multiple health hazards that have either spread internationally from the region, or having arrived from elsewhere, have found conducive environments in which to flourish. The 2003 SARS outbreak, which was precipitated by a novel coronavirus, resulted in approximately 8,000 cases including 800 fatalities, but caused an estimated $100 billion dollars in economic damage (Heymann 2005). In 2013 influenza reappeared again in China in the form of H7N9; but despite significant efforts by the Chinese Government, the virus has stubbornly refused to recede, resulting in annual epidemics that have continued to cause international disquiet (Hui, Lee, and Chan 2017). Lastly, as noted above, the Zika virus’ appearance in Micronesia, followed by French Polynesia, New Caledonia and Easter Island highlighted the intra-regional networks of travel and trade via which diseases can spread even amongst small island communities.

Given these multiple factors, it could perhaps be expected that the Australian Government would display a keen (self) interest in the health challenges emanating from the Indo-Pacific region. It is also the case that a regional focus aligns with Australia’s traditional approach to foreign policy, one which adopts a concentric circle approach – those countries closest to Australia receive the greatest attention, funding and priority, while those more distant receive less. For Australia, therefore, countries such as Papua New Guinea, Indonesia, the Solomon Islands, and Timor-Leste receive the lion’s share of Australian official development assistance (ODA), and health (linked with education) remains one of the government’s top six investment priorities (DFAT 2017, 2018a). Within this broader context, addressing the health risks with cross-border potential emanating from the region remains key, both with respect to protecting the health and wellbeing of Australia’s population as well as strengthening the health systems of neighbouring countries (Australian Government 2017).

Historically, governments of all political persuasions have tended to adopt a foreign policy focus on countries within their immediate region (Fawcett 2004). It is also the case that self-interest has also been a common feature of foreign policy decisions, especially with regards to the allocation of ODA (Hoeffler and Outram 2011). For these reasons it would be disingenuous for the Australian Government to be criticised for adopting a policy that has as part of its objective to help protect the Australian population. Moreover, given the disease burden that currently exists throughout the region, the variation in health system capacities, and the consequent human suffering, it should matter little whether enlightened self-interest or altruism is the primary motivation of the Australian Government’s new regional health security initiative. Conceivably, the more important consideration is whether the assistance offered is the assistance sought, and that it is offered in a manner consistent with the aims and priorities of the recipient countries.

The ‘problem’ of ‘health security’

Depending upon how it is measured, the securitisation of global public health has been underway for the better part of three decades. For some, the release of a 1992 report by the US National Institute of Medicine which cast contagious disease infection and control in terms of ‘emerging infectious diseases’ represented the origin of health securitisation (Weir 2015); whereas others point to the release of the United Nations Development Programme’s 1994 report on human security (Aldis 2008). For yet others, health securitisation did not begin in earnest until it was actively promoted by the WHO and collectively supported by Western states from 2001 onwards (Davies 2008). Either way, it is apparent that the policy discussion depicting health hazards such as infectious diseases as ‘threats’ to national, regional, or global health security has been underway for some time. Importantly, however, this reframing activity has not always been welcomed.

Within academe, for instance, the fault lines surrounding global health security have usually followed one of three trajectories. The first, and most often cited is best summarised by the phrase the ‘West against the Rest’. This assessment, often advanced by Foucauldian and post-structuralist scholars, argues the health security discourse is largely reflective of embedded power structures and the interests of high-income countries that seek to protect their populations from the diseases emerging from low- and middle-income countries. The corresponding accusation is that because this discourse perpetuates postcolonial and/or historical notions of superiority, it is morally and/or ethically compromised, and thus should be resisted and rejected (King 2002; Collier and Collier 2008; Stevenson and Moran 2015).

A second, central critique is that the health security agenda invites the participation of undesirable actors. Here the fault line arises over the inclusion of security sector personnel – and in particular, the military – into decision-making processes, which it is alleged, may result in unintended consequences. Amongst health and humanitarian communities, for example, anxiety appears to focus around two possible outcomes: (i) that by including security sector personnel the authority of health and medical professionals may be undermined or relegated to a secondary role; or (ii) that medical and/or humanitarian principles may be overridden in deference to security concerns (Elbe 2006; Enemark 2009; Ingram 2011). By comparison, security studies academics have highlighted that military, diplomatic, intelligence and law enforcement personnel consider that while health issues are clearly important, they are not ‘core business’, particularly when confronted with reduced military spending and fiscal tightening (Bernard 2013, 158).

The third fault line pertains to the distorting impacts that health security can have on the wider global health agenda. In this, detractors point to the fact that the focus on acute, fast-moving health ‘threats’ (i.e. infectious diseases, bioweapons, etc) may serve to undermine other, more pressing health concerns of low- and middle-income countries such as non-communicable and chronic diseases. The argument follows that this disproportionate focus creates, in effect, a hierarchy of health issues that may not be reflective of the genuine health needs of the majority of the world’s population (Greenberg 2002; Aldis 2008; Rushton 2011; Youde 2012; DeLaet 2015).

Beyond academic dissatisfaction, some governments have also previously expressed reservations about the health security agenda. This has notably included the governments of Brazil, Indonesia, India and Thailand who were especially vocal in their opposition from 2007 onwards, arguing that there was no consensus around the phrase and its use (Shashikant 2007, 2008). Brazil even publicly questioned ‘the goal of international public health security’ and when it would be ‘fully met’ (Executive Board 2008), indicating the intent behind the term’s use was decidedly unclear. Equally though, with the possible exception of Brazil, prior to 2014 these same governments were observed to be wildly inconsistent in their criticism, selecting at times to utilise the health security concept and language to advance domestic political agendas (Kamradt-Scott 2015). This suggests at the very least there were internal divisions within these governments around the utility of ‘health security’; but it did result in a notable reduction in the use of security concepts and terminology within key health policy forums such as the WHO’s annual assemblies.

Yet, in the aftermath of the 2014 West African Ebola outbreak it appears that opposition to global health security has effectively dissolved. The launch of the GHSA, the JEE Alliance, combined with other new entities such as the Coalition for Epidemic Preparedness Innovations (CEPI), the World Bank’s Pandemic Emergency Financing Facility (PEF), the WHO’s new Health Emergencies Programme (WHE), and the WHE contingency fund, have all been closely aligned with or linked to the concept of global health security. Moreover, global health leaders such as the Global Fund’s executive director, Peter Sands (2018), and the WHO’s director-general, Dr Tedros Adhanom Ghebreyesus, have also been prominent advocates promoting global health security, with the latter drawing explicit correlations with universal health coverage as being ‘two sides of the same coin’ (2018). As a result, while some governments may still hold some unspoken reservations as to the appropriateness of the health security frame, a consensus appears to have emerged that the framing of public health issues in security-related language and concepts is here to stay.

On said basis, it is understandable the Australian Government, which has been a long-term supporter of ‘global health security’, would adopt equivalent language to describe a new regional health initiative. This is seemingly not only despite the recognised fault lines described above, but irrespective of the fact that several countries within the Indo-Pacific region previously opposed the conflation of health and security. Suggestive of the self-interest ‘West against the Rest’ narrative, for example, Australia’s foreign minister Julie Bishop noted in announcing the regional health security initiative that, ‘Australia’s health security is linked to the health security of our Indo-Pacific neighbours’ (Bishop 2017c). Similarly, in justifying the investment, Greg Hunt, the Minister for Health, stated on 10 October 2017 that, ‘It’s in our national interests because if we have stronger and better health outcomes in our region, we ensure we have better health security for Australia’ (Cornish 2017). This same narrative was made even more explicit in the Health for Development Strategy 2015-2020 that noted DFAT’s investment in health ‘helps to protect Australia and our region from infectious diseases and other health challenges that pose major threats to Australia’s economic, trade, and political interests’ (DFAT 2015b, 4). Altruism in the form of a focus on ‘expanding partnerships’, ‘deepening people-to-people linkages’, and helping ‘prevent avoidable epidemics, strengthen early detection capacity, and support rapid, effective national and international outbreak responses’ is evident in DFAT’s public announcements about the new regional initiative (DFAT 2018b); but it also clearly the case that protecting Australia’s population from the risk of diseases and other health challenges emanating from the region is a strong motivator.

Notably, the emphasis placed on protecting Australian citizens has attracted criticism from elements of the academy, albeit it has to be acknowledged that to date this criticism has been muted. Stephen Howes (2017), a Professor of Economics at the Australian National University, in discussing the $300 million regional health security initiative stressed in a blog piece that it was ‘not additional aid money. Some of it is simply a continuation of existing funding arrangements’. Explicitly expressing concerns about the ‘West against the Rest’ narrative evident in the Australian Government’s public statements, Howes went further to question ‘Are we only prepared to spend funding on health in Asia if it might prevent a disease coming to Australia?’. Likewise, some weeks later Patel and Phillips (2017), also both academics based at the Australian National University, reasoned that ‘Conceptualising health as a ‘security’ challenge is a headline-grabbing exercise’, and argued that ‘[t]here are real possibilities that if one seeks [global health security] without addressing individual countries’ own [national health security], the health outcomes of countries in the region may be compromised in order to obtain Australia’s health security’. Similarly reflecting the concerns about the distorting impacts a focus on acute, fast moving health ‘threats’ can have, Barbara McPake from the University of Melbourne’s Nossal Institute of Global Health argued for a greater emphasis on non-communicable diseases, noting

there needed to be more awareness of the needs of countries. With aid programs such as Australia’s focusing on its own national interests of regional security, it could potentially result in domestic health concerns being swept aside in development assistance. (Cornish 2018)

It is also the case that the Australian Labor Party has been critical of the new initiative. With respect to the foreign aid budget cuts instituted under the Abbott Government and maintained by the Turnball Government, Australia’s foreign affairs opposition spokesperson, Senator Penny Wong, observed that, ‘[t]he unprecedented loss of bipartisanship in this area is disappointing for supporters of constructive internationalism, diminishes our reputation in the region, and is devastating for those who relied on it’ (Wong 2017). Wong (2017) went on to note, specifically with respect to the regional health security initiative that,

The new Regional Health Security Fund partnership may go some way towards repairing Australia’s ability to leverage additional sources of support and funding for development programs. But so far, 12 months after the fund was announced, the only thing of substance it has produced has been a Regional Health Security ambassador.

In a further indication that if Labor is returned to government the regional health security initiative may be cancelled, Wong (2017) went on to note,

As we develop our response to the health challenges of our region, Labor will work to deliver a program that best matches Australia’s ability to make the biggest impact on health outcomes and meets the health needs determined by our region.

Beyond these interventions, however, the majority of commentary has appeared to welcome the Australian Government’s new initiative. The Burnett Institute’s Chief Executive Officer Brendan Crabb, for example, released a statement in which he described the new initiative ‘as one of the most significant investments in regional health in recent times’ (Morgan 2017). Likewise, Anna George, an adjunct professor with Murdoch University and an associate fellow with Chatham House’s Centre for Global Health Security, described the investment as a ‘new and clever initiative’ (George 2017). The day after the official launch, Dr Shin Young-soo, the WHO regional director for the Western Pacific, also ‘very much’ welcomed the new regional health security initiative, observing that, Australia’s investment had been ‘invaluable’ in supporting ‘WHO’s work on health emergency preparedness and response and other health security threats in the Region’ (Shin 2017).

Importantly, however, the question remains as to whether the Australian Government’s focus on ‘health security’ is welcomed by its regional neighbours. The response to date appears to be resoundingly in the affirmative. Indeed, two years before the regional health security initiative’s launch in October 2017, the Asia Pacific Leaders Malaria Alliance (APLMA) Malaria Elimination Roadmap was endorsed by 18 leaders at the East Asia Summit in Malaysia. During the meeting, it was noted that the prevalence of malaria represented an ‘emergency – one that could have a disastrous impact on the region as a whole, as well as on global health security’ (Zweynert 2015). Significantly, Thailand, Indonesia and India – three countries that had previously expressed strong reservations about the conflation of health with security – endorsed the plan’s focus on the disease and its description as a global health security threat, suggesting that some of their previous concerns had been mitigated. In like manner, in September 2017 the SPC hosted the 12th Pacific Health Ministers Meeting in Noumea where they adopted the Pacific Health Security Coordination Plan (SPC 2017). While much of the document focuses on the impacts of climate change on human populations, it is nevertheless apparent that Pacific Island leaders are comfortable with the conjoining of health and security concepts, using the same narrative to advance their collective (and presumably domestic) health agendas. Likewise, at the fourth annual Australia-Papua New Guinea (PNG) Bilateral Security Dialogue in February 2018, the PNG Government concurred that regional health security was ‘essential’ to the ‘shared strategic interests of the two neighbours’ (Anonymous 2018). Although a wider, in-depth analysis of Indo-Pacific countries’ views and opinions is arguably warranted as the five-year initiative progresses, all indications currently suggest the concerns which various Indo-Pacific governments held around 2007 have now been resolved (see also Wenham 2018).

Further substantiating this, it is important to note that beyond the multilateral and bilateral forums other government-driven organisations also appear to support a focus on health security. Moreover, they appear to have been consistent in their use of health security concepts and language for several years. The Asian Development Bank, which is underwritten by some 48 Indo-Pacific countries¹, launched the Regional Malaria and Other Communicable Disease Threats Trust Fund (RMTF) in December 2013 (ADB 2018). This explicit focus on infectious diseases, their description as ‘threats’, and the fact that its member states appoint representatives to the ADB’s board of governors (thus exercising direct oversight of the organisation) suggests at the very least that this framing was either uncontroversial or acceptable to the majority, if not all, of the Bank’s investors. Similarly, in August 2013 the WHO’s SEARO – which notably includes Indonesia, Thailand and India – convened a regional meeting on zoonotic diseases in which the organisation’s regional director stressed the importance of APSED as a roadmap to ‘ensuring regional health security and contributing towards international health security’ (Plianbangchang 2013). In October 2015, the WHO’s Western Pacific Office co-organised a special side event on regional health security that was supported by the United States and the Republic of Korea, whereby Dr Shin Young-soo, observed

We all know that the Western Pacific Region is a hot spot for health security threats. Over the past decade, we have seen dangerous emerging diseases—such as SARS, avian influenza H5N1 and H7N9, and more recently, Ebola and MERS … This forum will highlight why health security is so important and why we must continue to build our capacities to prepare for and respond to these threats—especially in calm times. (WPRO 2015)

Conclusion

Despite the recognised fault lines and previous concerns surrounding the encapsulation of public health issues in security-related language and concepts, it would appear that – at least for the time being – ‘health security’ is here to stay. Moreover, it appears to enjoy sufficiently strong support from the majority of, if not all, governments of the Indo-Pacific region. In this context, the Australian Government’s decision to frame its most recent official development assistance package for health as focused on ‘regional health security’ appears to sit comfortably with the interests not only of Australian conservative politicians’ desire to (be seen to be) protecting the health of Australia’s population, but also – importantly – the regional recipients of Australia’s aid. Having said this, whether all of the concerns surrounding the securitisation of health have been addressed remains to be seen, as the new initiative has only just been launched. While it has been met with a largely positive reception to date, it is still early days, and the successful execution of the aid programme will be critical in determining how Australia’s neighbours view this initiative over the long-term.

As additionally noted above, it can be reasonably argued that the new initiative with its explicit focus on the Indo-Pacific region is both appropriate and fit-for-purpose. Several factors contribute to this, none the least being the region’s ongoing experiences with novel pathogens such as SARS, H7N9 and MERS, as well as the challenges around several existing infectious diseases such as malaria and tuberculosis and their drug-resistant varieties. Critically, however, when these microbial ‘threats’ are combined with the fact the region comprises two-thirds of the world’s population, where it is a region that already possesses high levels of urbanisation and where the trend for high-density living is only increasing, the level and extent of intensive farming practices and opportunities for human-animal interaction which facilitates the emergence of zoonotic pathogens, and the region’s extensive international air, sea and land connectivity with other parts of the world, it can be appreciated why the Australian Government might want to ensure the region is better prepared for detecting and containing health issues with the potential for transborder spread.

Having said this, two critical issues in the form of long-term funding and political support – both at the domestic and international level – remain. Any five-year government initiative runs the risk of being cancelled on account Australia’s election cycle is every three years, and new administrations arrive with new agendas and priorities. Given the political turmoil within Australian politics that has witnessed six Prime Ministers in as many years, it is entirely conceivable that further political change will ensue. Critically, the regional health security initiative does not currently appear to enjoy sufficient domestic bipartisan support to survive a change of government. Likewise, as noted above and elsewhere in this special issue, the US Government’s support of Obama’s GHSA initiative is also believed to be wavering. If cancelled, this would have a negative impact on Australia’s efforts; and while Australia’s regional neighbours have become used to wavering levels of ODA, cancellation of the initiative would likely further damage Australia’s standing in the region. Even if the initiative does survive and is left to run its full five-year term, given the health challenges throughout the region the only other question that remains is whether $300 million will be enough.

Disclosure statement

No potential conflict of interest was reported by the author.

Notes on the contributor

Adam specialises in global health security and international relations. His research and teaching explores how governments and multilateral organisations cooperate and interact when adverse health events such as disease outbreaks, epidemics and pandemics occur, as well as how they respond to emerging health and security challenges. Adam’s most recent research examines civil-military cooperation in health and humanitarian crises, and the correlations between gender, sexuality, health and security.

Additional information

Funding

This work was supported by The University of Sydney SOAR Fellowship.

Notes

1 ADB 2018 The Asian Development Bank has a total number of 67 members, including 19 members that are outside the region.