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The World Health Organization
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27 World Health Organization

Kelley Lee
The World Health Organization was established in 1948 as the United Nations
specialized agency for health. Its creation was preceded by a long history of
international health cooperation. The influenza pandemic of 412 BC, the Plague of
Athens in 430 BC (typhus), the Black Death (bubonic plague) of the fourteenth century,
and exchange of infectious diseases between the eastern and western hemispheres from
1492 (Crosby 1972) prompted early forms of cooperation to control epidemic diseases
across continents (Watts 2003). From the mid-nineteenth century, efforts began to be
more formalized via 14 International Sanitary Conferences held between 1851 and
1938. Four international conventions were agreed by 1903, which were later codified
and consolidated into the International Sanitary Regulations, the forerunner of the
present-day International Health Regulations. This was followed in 1907 by the
establishment of a permanent body, the Office International d’Hygiène Publique
(OIHP), to collect and report epidemiological data from member states. Following the
devastating influenza pandemic of 1918–19, which killed an estimated 25 million
people worldwide, the League of Nations Health Organization (LNHO) was created in
1920. The LNHO was envisioned as going beyond statistical collation and dissemin-
ation, organizing member states ‘to take steps in matters of international concern for
the prevention and control of disease’ (League of Nations 1919: Article 23(f)). This
desire to expand the scope of international health cooperation, however, was overtaken
by stronger political tides which saw the US withdraw from participating in the League
of Nations.
The US was active, however, in the formation of the regional Pan American Sanitary
Bureau (PASB) in 1902. Dissatisfied with the strong European focus of the Inter-
national Sanitary Conferences, the US Public Health Service played an active role in
shaping the PASB’s mandate and activities. Given limited resources, the regional body
initially focused on collecting epidemiological data, and facilitating the exchange of
information among member states and other health organizations. Over time, it took a
more active operational role, for instance, by initiating a yellow fever eradication
program (Fee and Brown 2002).
At the end of the Second World War, and amid post-war outbreaks of epidemic
diseases, world leaders agreed to convene a conference to discuss the creation of an
institution that would bring together existing regional and international health organ-
izations. It is perhaps curious that the task of creating a single world body was not on
the agenda of the UN Conference on International Organization held in 1945. This may
be explained by the focus, in the immediate aftermath of war, on emergency relief.
Urgent health care was provided by such organizations as the UN Children’s Emer-
gency Fund (UNICEF), created in 1946, and UN Relief and Rehabilitation Administra-
tion (UNRRA), founded in 1943 to give aid to areas liberated from the Axis powers.
504
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World Health Organization 505
To establish more broadly based international health cooperation, the International

Health Conference was held in June 1946, attended by all 51 members of the UN as
well as 13 non- member states, the Allied Control Authorities for Germany, Japan and
Korea, and observers from relevant UN bodies. During the four and a half weeks of the
conference, delegations agreed a constitution, a protocol for the termination of the
OIHP, and the setting up of an interim commission to assume its duties, and those of
the LNHO and the temporary UNRRA, until WHO could be established (WHO 1958:
44–5). The two-year interval between the conclusion of the International Health
Conference, and establishment of the organization, was unforeseen by those keen to see
the new agency begin its work. The main reason for this delay was the onset of the
Cold War, which dampened post-war internationalism, and led to debates about the
appropriate role for the UN. Amid rising East–West tensions, the American government
became wary of what it saw as ‘socialized medicine’. The assertion in WHO’s
Constitution, that health is ‘one of the fundamental rights of every human being’, and
the responsibility of governments ‘for the health of their people’, was viewed with
considerable suspicion by those who equated these principles with the rise of
Communism. Along with the pre-Second World War focus on epidemiological surveil-
lance and monitoring, critics of social medicine argued that the new organization
should limit its work to biomedical research and international cooperation on major
disease outbreaks (Lee 2008). This tension between a social medicine approach to
health, and one focused on disease surveillance and control, continues to permeate
debates about the organization’s reform to the present day. It is also in this historical
context that WHO’s contemporary role, in relation to the concept of health security, can
be understood.
NATURE OF SECURITY GOVERNANCE REGIME AND ROLE

OF WHO
Within the international community, WHO has played a prominent role in many disease
prevention, control and treatment campaigns, in some cases initiating and leading
collective efforts, in other cases serving as a key partner. The most high profile of these
has been several disease eradication campaigns. The global eradication of smallpox in
1979 is, to date, the organization’s most notable accomplishment. Other eradication
campaigns include malaria, which has been scientifically and operationally elusive
since the 1950s, poliomyelitis (hindered by political instability in the remaining high
burden countries) and dracunculiasis (guinea worm disease).
As discussed below, public focus on health security since the 1990s has concerned a
shift in attention to disease outbreaks, notably those deemed of international concern.
Such events are distinguished from routine disease prevention, control and treatment
programmes by their concern with diseases of an acute and potentially epidemic nature,
with the capacity to cause high rates of morbidity and mortality. Moreover, among such
epidemic diseases, those which pose an additional risk of spreading widely and rapidly
across larger geographic regions and even continents (that is, pandemics) are deemed a
particular threat to health security.
506 Handbook of governance and security
A leading international coordinating role by WHO, during such disease outbreaks

that span more than one member state, has been considered a core function of the
organization from its creation in 1948. This has involved the regular and emergency
convening of expert groups and scientific meetings; disease surveillance, monitoring
and reporting activities; and development and dissemination of protocols, guidelines
and other information to support disease prevention, control and treatment. These
so-called ‘normative activities’ have been distinguished from ‘technical assistance’ or
‘technical cooperation’ activities in the form of support for countries with insufficient
capacity to undertake certain public health functions themselves. The balance between
these two types of activities has been the subject of considerable debate, with some
arguing that the latter is beyond the constitutional and/or financial remit of WHO and,
instead, within the realm of health development agencies such as bilateral aid donors,
the World Bank, other UN bodies, nongovernmental organizations and philanthropic
foundations (Ruger and Yach 2008). In contrast, the roles of directing and coordinating
have been considered more appropriate ‘core functions’ for WHO.
By the late 1990s, in an effort to reassert the organization’s unique value in a rapidly
globalizing world, and in the face of growing competition from new global health
initiatives, security became a useful frame for these activities. The initial focus of the
health security agenda was HIV/AIDS, with WHO playing a major role in the eventual
adoption of UN Security Council Resolution 1308 in 2000 to limit the potentially
damaging impact of HIV/AIDS on the health of uniformed services personnel. In June
2011, the UN Security Council renewed its commitment to address the impact of
HIV/AIDS, on peace and security, by unanimously adopting UNSCR 1983 that calls
for increased efforts by UN member states to address HIV/AIDS in peacekeeping
missions. It also calls for HIV/AIDS prevention efforts among uniformed services to be
aligned with efforts to end sexual violence in conflict and post-conflict settings
(Feldbaum et al. 2006; Rushton 2010).
Security was recognized as a useful frame for ensuring health, more broadly, was
given due attention in the post-Cold War period. As part of WHO Director-General Gro
Harlem Brundtland’s diplomatic offensive, to raise the profile of health on the global
policy agenda, and WHO in particular as the lead institution in any system of global
health governance, she argued that health should be recognized as part of the new
security agenda:
[W]e need to redefine the notion of security in the age of globalization. Today I will be
responding to that message by saying: Yes – it is high time to revisit the notion of security
and fully appreciate the role of global health for the future of your country and the entire
system of international cooperation … Global health matters for their own health and security
and for the future of their children. Conditions of ill-health around the world directly and
indirectly threaten the lives of large numbers of Americans. (Brundtland 1999: n.p.)
Thus, amid debates about WHO’s leadership, and renewed concerns about communic-
able disease outbreaks, funding for health cooperation began to focus on enhancing
global health security. As discussed below, efforts to revise the IHR, somewhat stalled
in the mid-1990s, were given a needed boost to completion in 2005. This was
accompanied by new funding to improve disease surveillance, monitoring and reporting
of acute infectious diseases with epidemic potential (now referred to as health
emergencies of international concern). The theme for World Health Day 2007 was
designated as health security defined in terms of disease outbreaks. As described by
WHO Director-General Margaret Chan (2007):
We live in a world where threats to health arise from the speed and volume of air travel, the
way we produce and trade food, the way we use and misuse antibiotics, and the way we
manage the environment. All of these activities affect one of the greatest direct threats to
health security: outbreaks of emerging and epidemic-prone diseases.
The World Health Report 2007 maintained this theme, albeit defining global public
health threats of the twenty-first century more broadly to embrace epidemic-prone
diseases, food-borne diseases, and both accidental and deliberate outbreaks (toxic
chemical accidents, radio-nuclear accidents and environmental disasters). The report
identified the
first steps that must be taken towards global public health security, therefore, are to develop
core detection and response capacities in all countries, and to maintain new levels of
cooperation between countries to reduce the risks to public health security … This entails
countries strengthening their health systems and ensuring they have the capacity to prevent
and control epidemics that can quickly spread across borders and even across continents.
Where countries are unable to achieve prevention and control by themselves, it means
providing rapid, expert international disease surveillance and response networks to assist
them – and making sure these mesh together into an efficient safety net. (WHO 2007: xiii)
The pressures on WHO to undertake further reforms led the Director-General to set out
a programme of reform at the Executive Board in January 2012 that addressed the
organization’s ‘priority setting at a strategic level and the practical realities of resource
allocation’ (WHO 2012). Seven categories of priorities were identified, including the
‘surveillance of, and response to, disease outbreaks and acute public health emergen-
cies, and the effective management of humanitarian disasters’. A $15 million contin-
gency fund from voluntary contributions, to enable ‘surge capacity’ during outbreaks,
was proposed which would strengthen the WHO’s response and ‘ensure that response
teams can be on the ground quickly when an outbreak has been detected’. The proposal
reflected awareness that, while WHO held unique authority under the IHR to manage
and control international responses to such events, resource limitations have hampered
its capacity to fulfil this role (WHO 2011).
In all of the above, the nature of the health security governance regime has been
strongly focused on state authorities coordinated by WHO. While this role has been
complicated by the proliferation of global health initiatives, none to date have been given
equivalent authority. The extent of WHO’s authority extends to a limited degree to
regulatory powers under the IHR. However, as described below, the enforcement
capacity of the organization to ensure compliance has been problematic. This challenge
has led to a shift towards the reliance of non-state actors to play an increased, albeit
limited, role in improving disease surveillance, monitoring and reporting functions.
There remain unresolved tensions, however, regarding the norms to guide collective
action to act upon such information, with divergent views on the scope for intervention
by public and private actors to maintain health security.
EVOLUTION OF SECURITY GOVERNANCE ROLE ASSUMED

OVER TIME
The Securitization Process
Health has risen markedly on the international agenda, in large part, owing to its
securitization. There is nothing new about health as an international (crossborder) issue.
Infectious diseases have long transversed state boundaries and systems of international
cooperation, attempting to prevent and control their spread, long pre-date the establish-
ment of WHO in 1948. Moreover, there has long been humanitarian concern for
international health development through the work of philanthropic foundations, NGOs,
governments and multilateral organizations. What is different about recent attention to
health issues is the apparently successful attempt to move health beyond the social and
development policy agenda into the realms of foreign and security policy. For example
the Millennium Development Goals (MDGs) agreed in 2000 set three out of eight
goals, eight of the 18 targets and 18 of the 48 indicators as related directly to health;
the UN Security Council session of January 2000 was devoted to the threat HIV/AIDS
posed in Africa; UNSCR 1308 of July 2000 addressed the need to combat the spread of
HIV/AIDS during peacekeeping operations; the United Nations Special Session on
HIV/AIDS held in June 2001 declared the disease a security issue; World Health
Assembly Resolution 54.14 adopted in May 2001 on ‘Global health security: epidemic
alert and response’ focused on revision of the IHR; and the G8 Summit held in Genoa
in July 2001 agreed the creation of the Global Fund to Fight HIV/AIDS, Tuberculosis
and Malaria. The driving force behind this shift originated largely within the public
health sector, motivated by a desire to secure greater political attention to global public
health needs. Key players included WHO Director-General Brundtland, President of the
US Institute of Medicine Ken Shine, former World Bank economist Jeffrey Sachs, and
former US Ambassador to the UN and President of the Global Business Coalition on
HIV/AIDS, Richard Holbrooke. The target was both the foreign and security policy
communities which hitherto perceived health issues as primarily domestic and ‘low
politics’ concerns. From the perspective of public health advocates, differences between
the two communities have so far not been deeply explored, and the two are broadly
(though not always) seen in the same light. For the purposes of analysing public health
engagement with these policy communities, this lack of distinction is taken as given. In
1999 the US State Department cited the protection of human health as one of its
strategic missions (US Department of State 1999: 9, 41), and in its Strategic Plan for
Financial Years 2004-2009 stated
The United States has a direct interest in safeguarding the health of Americans and in
preventing the threats posed by diseases worldwide. Epidemic and endemic diseases can
undermine economic growth and stability, and threaten the political security of nations,
regions and the international community … emerging infectious diseases of epidemic or
pandemic proportions … pose a serious threat to American citizens and the international
community. (US Department of State 2004: 76)
The concept of health security emerged during the 1990s from a constellation of
factors. Foremost, perhaps, was the ending of the Cold War and the emergence of the
so-called non-traditional security agenda. Selected health issues formed part of this
agenda led by chemical and biological weapons. Concerns about the increased
proliferation and use of such weapons, notably by terrorists or ‘rogue states’, grew as a
result of the use of chemical weapons by the Iraqi government on the Kurdish
population in 1988, revelations about the Soviet biological weapons programme from
the late 1980s, and the Sarin gas attack on the Tokyo subway in 1995. Another source
of growing security concern was emerging (new) and re-emerging (new patterns or
strains) diseases. By the 1980s, infectious diseases were assumed in decline, at least in
the industrialized world, with improved living conditions, better standards of living and
advances in medical science. The emergence and spread of drug resistant diseases, and
the increased coming together of human and animal populations, in particular,
represented new threats that existing arsenals of medicines would not necessarily
protect against. Moreover, poor funding and neglect of public health systems world-
wide had weakened the capacity of governments to respond to such diseases. An
outbreak of cholera in Peru in 1992, plague in Surat, India in 1994 and, perhaps most
worryingly, avian influenza in Hong Kong in 1998, added to these rising concerns.
A rise in the above concerns coincided with a questioning of the leadership role of
WHO as the UN specialized agency for health. It is in this context that the concept of
health security became a prominent component of WHO activities from the mid-1990s.
Amid unprecedented criticisms by major donor governments of the organization’s weak
leadership, bureaucratic inefficiencies and unclear impact on the ground (Godlee 1994),
donor agencies began to channel resources through other organizations such as the UN
Cosponsored Programme on HIV/AIDS (UNAIDS), Global Fund to Fight HIV/AIDS,
Tuberculosis and Malaria (GFATM), and Global Alliance on Vaccines and Immuniza-
tion (GAVI). This proliferation of new institutional players, coinciding with a freeze in
real and later actual terms of WHO’s budget, led to intense reflection regarding the
organization’s core mandate and functions (Lee 2008).
The deliberate use of biological or chemical agents, with the intent of causing mass
deaths, major disease outbreaks or extensive poisoning in targeted populations, has
been a central component of the heightened concern about security threats from
terrorism since the 1990s, and especially since 2001. Culminating in the events of
September 2001, the result was growing discussion between the public health and
security communities in the US, and other major western countries, of the need to
improve the capacity to prevent and respond to a major bioterrorist attack. Within the
public health community, the focus was on enhancing responsiveness to such an event,
recognizing that ‘we will not be able to prevent every act of BW (biological weapon)
terrorism’ (Simon 1997: 428). Indeed, arguing that ‘the greatest payoff in fighting BW
terrorism lies in improving our response to an incident’, much effort has been
undertaken to anticipate strategic targets, improve surveillance, draft contingency plans
(Tucker 1997), stockpile vaccines and treatments, and train and immunize key health
personnel (Danzig and Berkowsky 1997). Within the security policy community, efforts
were made from 1994 to negotiate a legally binding instrument to strengthen the
Biological and Toxin Weapons Convention (BTWC) originally signed in 1972 (Pearson
1997), press so-called ‘rogue states’ to disarm, and improve intelligence on terrorist
organizations. In this respect, biological and chemical weapons became included in the
lexicon of ‘weapons of mass destruction’. As US President George W. Bush (2002)
stated, ‘Bioterrorism is a real threat to our country. It’s a threat to every nation that
loves freedom. Terrorist groups seek biological weapons; we know many states already
have them’. The covert and increasingly cross-border reach of bioterrorism led to a
flurry of national, regional and international activity aimed at preventing the develop-
ment and use of such weapons, and improving policy responses should they ultimately
be used.
Biological and chemical weapons first received attention from WHO in 1970 when
the organization issued guidelines on their health effects. This has since been supported
by additional guidelines, protocols and training materials on measures to protect
against, or respond to, various biological and chemical weapons. This has included the
updating and revision of the 1970 report, Health Aspects of Biological and Chemical
Weapons, entitled Public Health Response to Biological and Chemical Weapons: WHO
Guidance (WHO 2004). Immediately following the events of September 2001, WHO
called for increased public vigilance against deliberate infections and updated guide-
lines for public health responses:
There are three lessons from recent events: first, public health systems have responded
promptly to the suspicion of deliberate infections; second, these systems must continue to be
vigilant; and third, an informed and responsible public is a critical part of the response. Today
we are releasing revised guidance on responses to suspected anthrax infections. (WHO
2001b)
In May 2002, the World Health Assembly adopted Resolution WHA55.16 on ‘Global
public health response to natural occurrence, accidental release or deliberate use of
biological and chemical agents or radionuclear material that affect health’ (WHO
2002). To implement this resolution, a Chemical and Biological Weapons (CBW)
Working Group was established across WHO programme areas to better share
information, activities and experience. The group brought together WHO staff from
Communicable Disease Surveillance and Response, the International Programme on
Chemical Safety, Food Safety Programme, Water and Sanitation, Mental Health, and
Emergency and Humanitarian Action. The objective of the CBW Working Group has
been to promote a coherent WHO approach, and to foster collaboration and co-
ordination among the various sections of the organization. Information is also shared
with WHO regional offices, some of which have established similar groups. The vision
of an integrated global alert and response system for epidemics and other public health
emergencies, based on strong national public health systems and capacity, and an
effective international system for coordinated response, is pursued through WHO’s
Global Alert and Response (GAR) programme.
Internationally, as well as convening specialist meetings to discuss the health
implications of biological and chemical weapons, WHO has contributed actively to
diplomatic efforts to achieve a more effective BWC. This has largely been achieved via
inter-sessional Meetings of States Parties including a four-year programme (2012–16),
as mandated by the 2011 Seventh Review Conference of the BWC, aimed at
strengthening the implementation of the Convention and improving its effectiveness as
a practical barrier against the development or use of biological weapons. In December
2012, for example, WHO staff joined 500 participants from 107 countries to agree
measures on international cooperation and assistance, strengthening national imple-
mentation, science and technology, and Confidence Building Measures (UNOG 2012).
While WHO has supported an updated and strengthened collective response to
bioterrorism, there has been some resistance that the issue not define WHO’s
engagement with global health security in its entirety. This was especially so following
the SARS (severe acute respiratory syndrome) outbreak in 2002–03 which demon-
strated that a broader range of health issues potentially posed a threat to security. While
the case fatality rate of SARS proved lower than initially feared, the outbreak
heightened concerns about the global impact of a highly pathogenic disease outbreak.
SARS began in southern China in November 2002 and began to spread internationally
in February 2003. WHO issued global alerts on 12 and 15 March 2003, by which time
the disease had already spread from China to Taiwan, Singapore, Vietnam and Canada.
By the time the disease came under control in August 2003, 8422 cases had been
identified in 29 countries, with 908 fatalities (WHO 2003a:1; see also WHO 2003b;
Zhou and Yan 2003). In addition to public health concerns, the foreign policy
community was made acutely aware of the potential economic impact of global disease
outbreaks such as SARS (Knobler et al. 2004), with one estimate placing losses at $100
billion (NIC 2003). The macroeconomic effects of disease and poor health had already
achieved more prominent foreign policy attention, principally through the WHO
Commission on Macroeconomics and Health (WHO 2001a). Severe acute respiratory
syndrome served to reinforce interest by the foreign and security policy communities in
such outbreaks.
Within a context of heightened concern about the global risks from acute disease
outbreaks, SARS prompted efforts to strengthen and coordinate institutional structures
and processes within and across countries and regions. In some cases, policy responses
reflected a traditional territorial-based approach to security, resulting in measures to
fortify ‘at the border’ disease control such as screening of migrants (Spiro 2003). The
creation of the US Department of Homeland Security, complete with an Office of
Health Affairs, is an example of this approach. While redressing the weak capacity of
underfunded and long neglected public health institutions at the national level has been
a clear and urgent need, ‘at the border’ responses alone to disease prevention and
control, in an era of intensified globalization, has been recognized as insufficient. This
message has been well illustrated by the ongoing threat posed by pandemic influenza
viruses. Human cases of the highly lethal avian influenza virus H5N1, initially in Hong
Kong in 1997, and then in 15 countries as of March 2013 (WHO 2013a), has prompted
efforts to strengthen national and global pandemic influenza preparedness. The
influenza pandemic of 2009 (caused by H1N1), and the outbreak in China of H7N9 in
2013, has reinforced the need for global approaches to public health that address the
broad determinants and impacts of disease outbreaks. As Brundtland (2003) described:
[W]e cannot view health solely as an issue of how many people get ill and how many recover,
of who lives and who dies. We must look at why. And we should broaden debate to accept
that health is an underlying determinant of development, security, and global stability. We
must consider the impact of armed conflict and, perhaps more importantly, the silent march
of diseases that devastate populations over time – these are the stones that cause the largest
ripples, and the ones that go unnoticed until it is too late.
A further concern related to health security that emerged in recent decades has been
centred on illicit activities. It is estimated that organized crime generates $750 billion
annually, much of it ‘washed’ by complex financial transactions into the global
economy. As well as growing in scale, organized crime has become a global network of
criminal groups closely linked by supply and demand chains challenging the capacity
of national authorities (Niasco and Lamoth 1995). In relation to health security, at least
three forms of illicit activity raise particular concern. First, the trafficking of illicit
drugs had become a major challenge. Estimates of the total value of all sales of illicit
psychoactive substances range from $180 billion to $300 billion, with as much as
$122 billion annually spent in the USA and Europe on the three most popular drugs –
heroin, cocaine and cannabis. As much as $85 billion is laundered or invested in other
enterprises, a sum larger than the gross national product (GNP) of three-quarters of the
207 economies in the world (Stares 1996). This makes illicit drug trafficking one of the
biggest commercial activities in the world. In some countries, proceeds from the illicit
drug trade have been implicated directly in insurgency movements and terrorism.
A second, and related, activity is the trade in counterfeit medicines which can be
defined as a drug made by someone other than the genuine manufacturer, by copying or
imitating an original product without authority or right, with a view to deceive or
defraud, and then marketing the copied or forged drug as the original. Notwithstanding
disagreement about the precise definition of ‘counterfeit’, where the active ingredients
of a drug are not authentic, as well as posing safety risks to individuals, the poor
efficacy of such medicines can weaken disease control efforts within populations.
Efforts to date to combat this growing trade have focused on stemming supply at the
national level, with WHO (2013b) advising that
each country should develop appropriate medicines policy options, legislation, and enforce-
ment strategies in view of its own situation and availability of institutional framework,
professional and financial resources. The policies should aim at involving the Government, its
agencies, the pharmaceutical industry, drug importers and distributors, the pharmaceutical
profession, governmental organizations, public interest groups and consumer groups, etc. in
efforts to prevent the supply of counterfeit medicines.
At a global level, WHO has suggested that a more effective response to the threat of
counterfeit drugs could be the development of an international convention to control
trade in counterfeit and substandard drugs.
A third type of illicit activity related to health security is the smuggling and
trafficking of humans, and plants and animals, across borders. An accurate measure of
such activity is not possible, given the limited data available, but evidence suggests that
this is a trade growing in scale and reach. The UN Office on Drugs and Crime states
that migrant smuggling affects almost every country in the world (UNODC 2013).
Despite the signing of the Convention on International Trade in Endangered Species of
Wild Fauna and Flora (CITES), there is also a booming illegal trade in animal and
plants within countries (for example, bushmeat) and across borders. The human health
risks arising from this trade stem from the unknown transport of disease agents. The
World Health Organization has drawn attention to the health risks suffered by trafficked
persons, focusing on violence against women (WHO 2012), rather than health security
concerns. The rising risks of imported zoonoses, however, in relation to illicit activities
have been recognized (Pavlin et al. 2009).
Role Ascribed to Institution by Member States
To address the above range of perceived health security threats, WHO’s role has
focused on strengthening preparedness and response capacity among member states,
and enhancing technical cooperation across various operational levels, from the local to
the global in the event of a health emergency of international concern. One of its core
goals has been to improve capacities of national and international institutions for
enhanced coordination and collaborative efforts in risk management and crisis/disaster
response. At the Fifty-fourth World Health Assembly in May 2001, WHO urged
member states to participate actively in improving epidemic alert and response
measures to ensure ‘global health security’. WHO called on member states to
strengthen national, regional and global surveillance and response measures through
such systems as the Global Outbreak Alert and Response Network (GOARN). It has
also worked with the United Nations Disaster Management Training Programme to
develop a preparedness training module, based on risk management principles. The
intended audience for the module is decision-makers, managers and other government
officials at the country level, plus their in-country counterparts from UN agencies,
including members of the United Nations Disaster Management Teams. Other potential
target groups include NGOs, donors, and, where appropriate, representatives of the
private sector.
Underpinning these activities has been a range of normative activities to guide
member states and other institutional actors. This has entailed the agreement of
guidelines, strategic plans and frameworks for ensuring such capacity. For example,
WHO has worked with member states to develop national pandemic influenza
preparedness plans including the provisions for producing, stockpiling and sharing
vaccines and drugs. The revision of the IHR in 2005 has been followed by efforts to
ensure member states have the disease surveillance and reporting capacity to fulfil its
commitments under the new agreement. Alongside new disease risks, globalization has
been recognized as bringing opportunities to improve the capacity of public health
institutions to respond more effectively to infectious disease outbreaks. Foremost is the
advent of new information and communication technologies which, in principle, enable
faster, cheaper and more efficient gathering and sharing of knowledge. ProMED-mail,
an Internet-based reporting system, and regional disease surveillance networks have
facilitated the collection and reporting of epidemiological data.
CASE STUDIES: KEY INSTRUMENTS OF GOVERNANCE

International Health Regulations
The International Sanitary Regulations (ISR) was first adopted by the World Health
Assembly in 1951, based on measures adopted by International Sanitary Conferences
dating from the nineteenth century. Initially applying to six diseases, the renamed
International Health Regulations were reduced in scope in 1969 to four diseases –

smallpox, cholera, plague and yellow fever. The confirmed eradication of smallpox in
1981 further reduced the diseases subject to the IHR to three. By the mid-1990s, this
narrow scope was seen as increasingly problematic in light of several emerging and
re-emerging diseases such as HIV/AIDS, West Nile virus and multi-drug resistant
tuberculosis (WHO 1997: 15–16). In addition, disincentives by governments not to
report naturally occurring disease events have grown because of the adverse economic
effects that can result (for example, the Latin American cholera outbreak in 1991 and
the Indian plague outbreak in 1994). Revelations about the Iraqi and former Soviet
biological and chemical weapons programmes have added further concern that the old
IHR, and indeed WHO’s entire governance framework for disease outbreaks, need
strengthening (Minze et al. 1998: 73).
The revision of the IHR agreed in 2005, with the new regulations coming into effect
from 2007, introduced important changes to address the above concerns. On disease
surveillance, to avoid dependence on government information sources, the 2005 IHR
makes provision for the use of a wide range of state and non-state sources including the
mass media and scientific community. Another important change is the expansion of
the scope of the IHR, beyond specifically named diseases, to the broader term of
‘public health emergencies of international concern’ including human and natural
disasters.
Pandemic Influenza Preparedness Framework
The institutional framework for international cooperation on influenza was born in

1946 alongside the creation of WHO. Recalling the 1918–19 pandemic, the post-war
system sought to plan for future influenza pandemics; develop control methods to limit
the impact of a pandemic; and limit the economic consequences of influenza. In 1947,
the World Influenza Centre (WIC) was created in London to collect and distribute
information, conduct and coordinate laboratory work, and train laboratory technicians.
The Global Influenza Surveillance Network (GISN) underpinning the entire system was
established in 1952, operating via WHO Collaborating Centres (CCs), which receive
influenza virus samples from National Influenza Centres (NICs), and undertake
analysis to identify circulating virus strains. This data is then passed to pharmaceutical
companies to develop seasonal or pandemic influenza vaccines. In 1952, an Expert
Committee on Influenza was formed to provide technical advice and general oversight
(Payne 1953: 763). Today, augmenting GISN’s work is the Internet-based FluNet,
linking NICs and WHO CCs, to ensure rapid global exchange of surveillance and
epidemiological data on circulating subtypes (Flauhalt et al. 1998).
In early 2007, the Indonesian government announced that it would cease sharing
H5N1 influenza virus samples with the GISN. The government argued that samples
provided were being passed by WHO to pharmaceutical companies that, in turn,
developed and patent protected influenza vaccines that Indonesians found to be either
too expensive to purchase or bought up under contract by high-income countries. As
well as gaining widespread support among advocates of equitable access to medicines,
the Indonesian government was also criticized for undermining global health security.
To find a solution, WHO initiated intergovernmental negotiations to agree a framework
for influenza virus-sharing. Over the next four years, concerned governments engaged
in talks and the process concluded in 2011 with the Pandemic Influenza Preparedness
Framework (PIPF) agreed at the Sixty-fourth World Health Assembly. Importantly,
negotiations focused on an agreement to facilitate the rapid sharing of influenza virus
samples with human pandemic potential, and to ensure greater access to vaccines and
associated benefits (WHO 2011). To achieve these objectives, the PIPF identifies
principles, norms, governance mechanisms and oversight arrangements that all mem-
bers of the WHO’s global influenza surveillance and response system (GISRS) and
other allied institutions are expected to comply. The document outlines, for example, a
series of recommendations relating to the sharing of influenza viruses with pandemic
potential, diagnostic equipment, laboratory and disease surveillance capacity building,
medication stockpiling, technology transfers and tiered pricing.
One of the core benefits of the PIPF is the range of obligations placed on
pharmaceutical companies that utilize GISRS information and virus samples. For
example, under the terms of the agreement manufacturers that are members of the
GISRS must now contribute 50 per cent of the network’s overall running costs.
Although details are not provided on how costs are to be shared among companies (that
is, ability to pay, percentage of overall profits), this transforms what was previously a
publicly financed network (supported by Japan, Australia, the USA and the UK) into a
new public–private partnership. Companies that are not members of GISRS (and thus
exempt from contributing operating costs) are required to agree to a package of
measures designed to promote improved access to medicines and diagnostics for
low-income countries in exchange for access to data and samples (Kamradt-Scott and
Lee 2011).
CONCLUSION
Health as a non-traditional security issue emerged in the 1990s following the end of the
Cold War. The immediate focus was on those health issues that pose a ‘clear and
present danger’ to states, namely acute and potentially epidemic (or even worse
pandemic) disease outbreaks that potentially cause high morbidity and mortality. With
the increased framing of global health in security terms, WHO has been expected, and
has also aspired, to play a key role in collective action to address them. Where
outbreaks of such diseases have occurred, or are believed likely to occur, member states
have looked to WHO to act decisively to direct and coordinate health cooperation.
The linking of WHO’s mandate and activities with health security has been, in part,
a strategic response to the criticism that the organization has experienced since the
1990s. One familiar argument is that WHO’s mandate has become unclear and too
broadly based. Reform efforts since the late 1990s have included calls to prioritize core
functions including health security. Events such as the anthrax attacks, SARS outbreak
and influenza pandemic have added impetus to the recasting of international health
cooperation in such terms, with a particular focus on disease surveillance and
monitoring, and rapid response. The rejuvenation of WHO in these terms, however, has
not been without controversy. Some have argued that this is a return to the original, and
overly narrow, mandate of the International Sanitary Conferences. Others have argued
that WHO should turn away from disease-focused initiatives, seeking instead to build
public health systems and capacities from the ground up. Global health development,
rather than global health security, notably in low-income countries, is argued to be the
best way of securing the health of all (Aldis 2008).
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27 World Health Organization

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To establish more broadly based international health cooperation, the International

NATURE OF SECURITY GOVERNANCE REGIME AND ROLE

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A leading international coordinating role by WHO, during such disease outbreaks

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EVOLUTION OF SECURITY GOVERNANCE ROLE ASSUMED

The Securitization Process

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Role Ascribed to Institution by Member States

CASE STUDIES: KEY INSTRUMENTS OF GOVERNANCE

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International Health Regulations were reduced in scope in 1969 to four diseases –

Pandemic Influenza Preparedness Framework

The institutional framework for international cooperation on influenza was born in

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