Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science
Volume 11, Number 2, 2013 ª Mary Ann Liebert, Inc.
DOI: 10.1089/bsp.2013.8522
Perspective
Health and National Security:
A Contemporary Collision of Cultures
Kenneth W. Bernard
P
ublic health and national security have always
been uncomfortable bedfellows. The discordant relationship is based on a kind of tribalism, which I define here
as the behavior and attitudes that stem from strong loyalty
to one’s own social group. A functional disconnect between
health and security is based on the innate interests and
culture of 2 tribes: the public health community (or tribe)
and the national security community (tribe). The 2 tribes
differ on what they perceive as priority issues.
But how can one set national priorities when comparing
the loss of security, life, and livelihood resulting from political instability in Libya or Syria to a catastrophic earthquake and cholera in Haiti? Those who try inevitably fail,
and, worse, they can look naı̈ve. Chemical weapons in
Syria, a flu epidemic in China, and foodborne diseases
causing death in the United States all can shake up the more
comfortable and traditional separation of health and security. The failed attempt to acquire DNA from Osama Bin
Laden or his family by using a health worker as cover has
highlighted the dangers of these conflicting priorities.
The 2 tribes work together when they have to, but
generally they would rather leave each to deal with its own
self-defined issues. This self-segregation is not dissimilar to
the medical world between, say, neurosurgeons and pediatricians. Most often the 2 specialties attract different kinds
of people with different personalities, interests, skills, and
training. They acknowledge the importance of each other’s
medical specialty but are uncomfortable with the intrinsi-
cally different approaches to their trade. And so it is true
when comparing the national security and public health
tribes.
Others have offered similar arguments describing the
civilian-military gap and even the basis of partisan disputes
between Democrats and Republicans. Rosa Brooks from
Georgetown University wrote recently, ‘‘At the national
level, however, the costs of the civilian-military gap are real,
and high. Such mutual ignorance—and such systematic
cultural differences in how to think about problems and
solutions—leads frequently to misunderstanding, inefficient decision-making, and, too often, bad policy.’’1
The intersection of national security and health communities and programs has been a poster-child for this
problem. The history of US support for international HIV/
AIDS control provides an example.
In January 2000, US Ambassador to the UN Richard
Holbrooke called for, and Vice President Al Gore chaired, a
landmark United Nations Security Council meeting on the
global security impact of HIV/AIDS—the first Security
Council session on a health issue in more than 4,000
meetings. Later Ambassador Holbrooke recounted, ‘‘. I
was told by everyone, including my own staff, ‘You can’t do
this; it’s not done; it’s not in the U.N. charter.’ And I said,
‘But AIDS is a security issue, because it’s destroying the
security, the stability of countries.’ ’’2
By April of that year, the Clinton administration had
formally designated AIDS as a threat to US national
Kenneth W. Bernard, MD, is former Special Assistant to the President for Biodefense, Homeland Security Council; former Senior
Adviser for Health and Security, National Security Council; and Assistant Surgeon General and RADM, US Public Health Service
(Ret.).
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HEALTH AND NATIONAL SECURITY
security that could, as was reported by Barton Gellman in
the Washington Post, ‘‘topple foreign governments, touch
off ethnic wars and undo decades of work in building freemarket democracies abroad.’’3
In August 2000, the National Security Council convened
a regular weekly staff meeting in the White House situation
room. The first 45 minutes of the meeting consisted of the
detailed recounting and lively group discussion of the political implications of the recent accidental explosion and
sinking of the Russian attack submarine Kursk in the
Barents Sea, with the death of all 118 crewmembers. Toward the end of the meeting, I asked the attendees, some of
the smartest foreign affairs and security mavens in the
Clinton administration, if I could ask for advice regarding a
State Department cable received that morning from Swaziland. King Mswati had just given a speech on HIV/AIDS
in the Swaziland National Stadium in which he declared
that over 30% of adults in his country had been infected
with HIV and most of a whole generation, more than
200,000 of his people, were most likely going to die from
AIDS. There was silence in the situation room, with shuffling of feet and a bit of murmuring. Finally, it was concluded that something more should be done, but no one had
any good specific options—unlike with the Kursk incident.
Just 3 months after the shocking cable from Swaziland,
Sandy Berger, President Clinton’s National Security Advisor, referred to health, security, and specifically HIV/
AIDS in an article in Foreign Affairs: ‘‘. a problem that
kills huge numbers, crosses borders, and threatens to destabilize whole regions is the very definition of a national
security threat.. To dismiss it as a ‘soft’ issue is to be blind
to hard realities.’’4 But 2000 was an election year, and new
policy and budget initiatives such as this were put on hold.
Two years later, in his January 2003 State of the Union
address, President George W. Bush announced the President’s Emergency Plan for AIDS Relief (PEPFAR) with an
unprecedented 10-fold increase in budget to attack the
international problem of HIV/AIDS. In addition, he
named an ambassador at the Department of State to oversee
the program. Importantly, by focusing not only on prevention but also equally on the treatment of the millions
already affected, PEPFAR directly contributed to the social,
economic, and political security and stability of many nations. President Obama has continued to support PEPFAR,
considered one of the most successful foreign aid programs
in recent history.
The (eventual) successful collaboration on HIV/AIDS
among the security, development, and health communities
was a difficult 10-year effort that required personal buy-in
from 3 consecutive presidents, the secretaries of State and
Health and Human Services, and more than a few skeptical
congressmen and senators.
Many in the diplomatic, defense, intelligence, and law
enforcement communities that do not regularly deal with
global health issues argue that, while they are ‘‘clearly very
important, they are not really our core business.’’ Public
health experts often are reluctant to trust those in the security community they see as coming from the ‘‘dark side.’’
However, accepting the mutual interdependence of security
and health is unavoidable—and, at the very least, clearly in
our enlightened self-interest as we redefine national security
in a post–Cold War world.
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Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science
Why Health Now?
Throughout most of the 20th century, the connection between disease and security took a back seat to the major
political issues, wars, and ideological battles of the day. But
that was to change with 3 significant historical markers: the
end of the Cold War in 1991, the emergence of HIV/AIDS
in the 1980s, and the rapid intensification of the globalization process dominated by market forces and nonstate
actors.
Much of the post–World War II era focused on a bipolar war of words, values, ideologies, and balance of
power between the 2 nuclear superpowers, the United
States and the Soviet Union (in concert with their respective NATO and Warsaw Pact allies). The 1989 fall of
the Berlin Wall and the 1991 end of the Soviet state
heralded a dramatic reevaluation and rebalancing of global
security issues. No longer under the imminent threat of
‘‘mutually assured destruction,’’ the superpowers’ other
security concerns were unmasked. New regional and intracountry conflicts pushed global hegemony from the
front pages. The wars in Iraq, the ‘‘Arab Spring,’’ and
conflicts in Afghanistan, Syria, Sudan, Lebanon, Israel,
Bosnia, East Timor, Somalia, Sri Lanka, and Mali are
examples. Tensions between countries increasingly take
the form of trade battles, nuclear proliferation, genocide,
cyberterrorism and cybercrime, violence against women,
pandemics, civil wars and uprisings, and asymmetric
threats such as terrorism, both national and international.
National security in the past 20 years has, as a result,
expanded beyond the traditional value of protecting the
sovereign boundaries of the nation. Former UN Secretary
General Kofi Annan wrote that problems such as pollution, organized crime, and the proliferation of deadly
weapons of mass destruction ‘‘show little regard for the
niceties of borders; they are problems without passports.’’5
Health Is Important, but I’m Busy
Traditionally, national security is the protection of a state’s
territory and political boundaries, population, and interests
against external threats through the exercise of political,
military, and economic power. In the past, most national
security threats were seen as largely military, macroeconomic, and foreign. But the critical concept in the traditional approach to national security is the responsibility of
the sovereign ‘‘state’’ to provide for that security.
BERNARD
The United Nations Development Program has argued
that the individual should replace the nation-state as the
focus for anticipating and dealing with threats. In 2003
former UN High Commissioner for Refugees Sadaka
Ogata and Nobel Prize–winning economist Amartya Sen
submitted a report, Human Security Now, to UN Secretary
General Kofi Annan. This report notes that human security
includes ‘‘. creating political, social, environmental, economic, military and cultural systems that together give
people the building blocks of survival, livelihood and
dignity.’’6
While most people can agree on the core concepts of
human security, many disagree with its practical application to altering the responsibilities of traditional stateoriented national security. There are 3 major criticisms
of the push to move the global security paradigm from
a nation-state national security focus to a person and
community-oriented human security focus: (1) it merely
adds a new set of economic and social concerns (freedom
from want) to the traditional political and sovereignty issues (freedom from fear) without providing solutions that
can be practically applied; (2) it is too idealistic, failing to
take into account real-world geopolitical competition for
power, sovereignty, and resources; and (3) it is vague and
attempts to be too comprehensive: When everything is a
security issue, then the term security loses its meaning and
priorities cannot be readily set.
There is another, more sensitive reason for taking special
care when discussing health as a security issue. The lead
government agencies dealing with security are the powerful
‘‘up table’’ defense, foreign affairs, and finance ministries,
not the weaker ‘‘down table’’ health and development
ministries. Health professionals and organizations generally
have little experience in crafting messages and issues that
speak to the critical power players who have foreign policy,
intelligence, and defense credentials. But it is not solely
their fault. The security sector is not enthusiastic about
being told that issues such as pandemics, about which they
had minimal training at the Kennedy School, Georgetown
School of Foreign Service, University of Chicago Law
School, the military war colleges, or the FBI academy,
should be considered ‘‘front burner’’ security problems.
When speaking or writing about global security issues,
the public health tribe often assumes that a common set of
priorities and agendas are shared across government and the
private sectors. This can be a fatal ideological and communications error. Not everyone in the security tribe is
willing to put anthrax or HIV/AIDS prevention before
counterterrorism, regional hegemony, nuclear nonproliferation, or the global economy. The global health lobby fills
books and op-ed pages with symbolic finger shaking at the
rich countries, making the ideological split worse. ‘‘For a
few dollars taken from their defense or security budgets and
put into health systems, we could alleviate poverty and
disease from the planet,’’ they say. This is very well meaning
but—let’s be frank—it is more than a little overwrought.
Volume 11, Number 2, 2013
These budgets have never been interchangeable, given the
realpolitik of our systems. Worse, pushing the ‘‘everything
is security’’ approach is off-putting to those senior officials
in government and the private sector whose responsibilities
and budget mandates involve more traditional security and
economic issues. This is most obviously seen when public
health advocates (and, recently, the United Nations) try to
make the case that chronic diseases like diabetes, heart
disease, and cancer are clear national security issues.
HIV/AIDS: A Security Argument
After the global changes resulting from the end of the Cold
War, the second historical event that expanded the global
importance of health and security was the recognition of
HIV/AIDS in the early 1980s, one of the most noteworthy
emerging threats to human security in recent history. The
global death toll from AIDS by the end of 2011 was over
35 million, mostly in Africa. The deaths now exceed that of
the Black Death (bubonic plague) in Europe in the 14th
century that killed 30% to 60% of Europe’s population
at the time and caused seismic changes in political and
economic hegemony.
The International Crisis Group has noted that HIV/
AIDS can have similar political and economic effects:
Agricultural production and food supply can become tenuous. Families and communities can break apart, and divisions among ethnic and social groups can deepen.
Economic progress can be threatened, worsening trends
that can lead to humanitarian catastrophe and violent
conflict. Community stability and good governance can
become threatened. HIV/AIDS affects educated populations as well as the poor, including civil servants, teachers,
healthcare workers, and police. Vulnerable children orphaned by HIV/AIDS can be induced to join militias,
criminal networks, and the commercial sex trade.
An appreciation of the political, economic, and security
effects of HIV/AIDS has helped many countries raise their
domestic political and budget focus to a level necessary to
combat the pandemic. As a result of national and international initiatives with major diplomatic and security sector
buy-in, about 8 million people in the developing world are
now receiving anti-HIV therapy, up from 700,000 in 2004.
In the past 10 years, HIV/AIDS, while still a threat to
millions, has become a treatable disease, although resource
deficits still result in only 54% of those who need treatment
medicines actually getting them.
Terrorism and Non-State Actors
A third significant historical event affecting health and security is the result of globalization: accelerated transnational flows of goods, services, finance, technology,
information, people, and disease. Globalization involves
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HEALTH AND NATIONAL SECURITY
state but also bypasses normal state structures with substate actors including civil society, political and economic
interest groups, and threats from individuals such as cyberand bioterrorists, all acting beyond the ready control of
nation-states.
The threat of bioterrorism most easily demonstrates the
interrelationship of health and traditional security issues to
the foreign affairs, defense, and intelligence agencies. The
anthrax attacks in the United States following September
11, 2001, caused only 22 cases and 5 deaths, but they
affected almost every sector of American society from the
postal system to transportation security to Congress. Protecting the heartland became as important as protecting the
national borders. Since 2001, the United States has spent
over $50 billion on biodefense preparedness including,
inter alia, training of first responders; development of new
medical countermeasures for smallpox, anthrax, and other
infectious threats using the BioShield fund; and installation
and improvement of the BioWatch early warning system
that samples air for biologic threats in more than 30 US
cities. Of recent concern, as access to biotechnology becomes more widely available, is the rising threat of new and
dangerous organisms being created intentionally or by accident in small labs around the world.
Bugs, Birds, and Planes
Other changes resulting from globalization, especially the
ease of airline travel and trade, have raised concerns about a
potential new human influenza pandemic that could rival
the scope and impact of the infamous ‘‘Spanish flu’’ over
90 years ago. Genetic variants like H1N1 caused between
150,000 and 575,000 deaths worldwide in 2009. Additionally, more than 600 highly dangerous H5N1 (avian
or ‘‘bird flu’’) influenza cases have been reported in patients
since 2003 in Azerbaijan, Cambodia, China, Djibouti,
Egypt, Indonesia, Iraq, Thailand, Turkey, and Vietnam,
mostly in those with close contact to sick poultry. The
fatality rate of H5N1 avian flu in humans is over 60%.
While there has been occasional transmission of H5N1
from person to person, sustained human-to-human transmission of the disease has not been seen—yet.
In early 2013, a new strain of influenza A—H7N9—was
reported from China. As of the end of April, there were 126
human cases and 24 deaths reported. No sustained humanto-human transmission has yet been documented, but there
is global concern among scientists that the continued spread
of H5N1 or H7N9 virus in birds and domestic poultry
more globally could result in mutations that could lead to
efficient transmission and a catastrophic human pandemic.
Lawrence Fishburne’s line in the 2011 movie Contagion
summarizes the problem well: ‘‘Someone doesn’t have to
weaponize the bird flu—the birds are already doing that.’’
But it is not just human deaths from influenza that have
an impact on our global security. The economic costs of
4
culling poultry and other H5N1 control measures in the
agricultural sector in Asia were estimated to be $10 billion
in 2005 alone. In Hong Kong, they slaughtered every
chicken in the country. The resultant economic decimation
of family and backyard flocks of chickens and ducks is
having a profound effect on family income in poorer
populations that can ill afford the losses. In an interconnected world, it has become clear that a human influenza pandemic, established and uncontained, would easily
pass through porous borders and eventually affect people in
every country, rich and poor, industrialized and developing.
The World Bank calculated that the global economic cost
of a major human avian influenza pandemic would be at
least $1.2 trillion.7 In light of these considerations, the
response to this potential health and security threat could
set a new standard for global cooperation and act as a model
for intersectoral cooperation on many other health and
security concerns.
What Should Be Done?
The ongoing academic and ideological debate over the relevance of human security versus the traditional sovereign
state focus of national security is distracting. Although discussion can be informative (especially in the academic environment), it deflects us from pursuing the far more critical
and practical solutions that will benefit our national and
international security now. We cannot afford to develop
only ‘‘visions’’ for global health, including grand statements
about equity and solidarity that are more about righteous
indignation than the implementation of good public policy.
Security events not usually considered health issues—
including civil unrest, organized crime, civil wars, natural
disasters, chemical weapons use, and migration—have clear
health dimensions. Conversely (with a hat tip to the human
security agenda), healthy people, families, and communities
provide the basis for economic and social development,
state sovereignty and stability, and reduction of international threats. In fact, research shows the 3 variables that
best predict ‘‘state failure’’ are the degree of openness to
trade, the level of democracy, and, unexpectedly, the level
of infant mortality. But just saying health is important does
not readily convert to setting priorities for action. It is incumbent on the public health community to persuade
foreign policy, diplomatic, defense, and senior private
sector officials that health is an integral part of what they
do, not just a soft collateral issue to be done by others. This
is not an easy task.
The following are examples that represent transnational
health/security issues whose importance simultaneously
conflicts with overlapping and difficult administration,
budget, and congressional committee oversight:
Plans to prevent, prepare, and respond to catastrophic
health events such as would result from a Fukushima-type
Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science
BERNARD
nuclear power plant incident, pandemic H7N9 influenza
in humans, or an anthrax attack—any of which could
undermine our security, safety, and economic stability;
Biodefense and bioterrorism preparedness, including
threat assessment, prevention, deterrence, dissuasion,
surveillance, detection, response, and recovery as a unified set of issues;
Response to NATO Article 5 requests for medical
countermeasures from the domestic Strategic National
Stockpile;
Global production of, trade in, counterfeiting of, and
intellectual property rights for critical drugs and vaccines;
Implementation of international multilateral agreements
such as the Biologic Weapons Convention, International
Health Regulations, and the Framework Convention for
Tobacco Control;
Contamination (intentional or natural) of the increasingly internationally sourced US food supply;
HIV/AIDS and other disease threats that present as humanitarian, economic, and potentially political problems; and
International refugee crises, famine, and sex and child
trafficking.
Shared technical advances in surveillance and science,
leadership, and intersectoral communication are 3 keys for
progress. Attempts by the departments of Health and
Human Services, State, Homeland Security, and Defense
and the Agency for International Development to take the
lead on health and security issues without central White
House direction have led to agency turf battles and
sandbagging of joint programs when they required sharing
of resources or information. The classic example is the
congressionally mandated and longstanding attempt to
develop a national biosurveillance program, for which data
would be shared with DHS in real time by HHS (including the Centers for Disease Control and Prevention),
the Department of Agriculture, DOD, and other agencies.
After years of slow progress, it took the National Security
Council (NSC) stepping in recently with a presidential
order. President Obama noted, ‘‘As a Nation, we must be
prepared for the full range of threats, including a terrorist
attack involving a biological agent, the spread of infectious
diseases, and food-borne illnesses. The effective dissemination of a lethal biological agent, for instance, could
endanger the lives of hundreds of thousands of people
and result in untold economic, societal, and political
consequences.’’8
Focused Leadership
In 1998, President Clinton established a health and security
office at the White House; it was abolished by President Bush
in 2001, and then reestablished and expanded after the 2001
anthrax attacks. The office acted as a common focal point for
Volume 11, Number 2, 2013
international health policy and became a critical forum to
harmonize national security and global health priorities. The
incoming Obama administration reorganized the NSC,
which absorbed the Homeland Security Council, and again
has abolished the Health and Security Directorate. The current structure divides the health/security portfolio into at least
3 different NSC directorates: development, nonproliferation,
and preparedness/resilience—all of which have significant
other primary responsibilities. Perhaps as disorienting as the
balkanization of the policy focus, some collateral damage also
results from the splintering of the Office of Management and
Budget crosscutting program and budget support for the issues. This overall White House structural problem has inadvertently resulted in downgrading health and security to a
second- or third-level priority.
Strategic global health and security would be better and
more consistently focused if staff were again coalesced under the leadership in the White House of one special assistant to the president for health and security. The policies,
agencies, and crosscutting budgets would be better coordinated, the American people more efficiently served, and
the administration would better realize international leadership in health and security issues.
Further, the State and Defense departments and the
intelligence community must develop incentives so the best
staff will choose jobs dealing with unconventional transnational issues such as health. This could be most readily
done by providing the same rewards and promotions that
usually are associated with the more traditional security
career paths leading to senior leadership positions, such as
NATO or near eastern affairs.
Communication is the other keystone for the needed
change. Published in 2007 by the nonprofit CNA Corporation and with the advice of former admirals and generals, the report National Security and the Threat of Climate
Change uses phrases that speak to the security community
in their own language: ‘‘disrupt our way of life,’’ ‘‘political
instability and failed states,’’ and ‘‘vulnerability to hostile
regimes and terrorists.’’9 As discussed above, the International Crisis Group did the same for HIV/AIDS. The
global health policy community should read these documents carefully and take guidance on their tone and style.
Former Republican Senate Majority Leader Bill Frist (a
physician himself ) has adopted the right voice for speaking
the tribal language of the security community: ‘‘It is in the
strategic and national interest of the United States of
America,’’ said Dr. Frist, ‘‘People don’t usually go to war
with people who helped save their children.’’10
At the beginning of the 21st century, we have many important concerns vying for our leaders’ attention, such as
worsening economic stability, global climate change, ethnic
hatred and regional conflicts, radical fundamentalism, terrorism, and inequitable economic development and trade. In
the context of these issues, the public health community must
do more than declare its moral outrage. The health community must temper its tribal convictions and convince
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HEALTH AND NATIONAL SECURITY
powerful defense and foreign affairs communities to embrace
relevant health issues in the first tier of policy and budget
concerns. They can start by speaking national security language and eliminating the self-important and sanctimonious
lecturing for which global health advocates are known.
National Security and the Threat of Climate Change has given
us a model for improved intersectoral communication.
Senator Frist has provided a clue as to the tone. Now it is up
to the global health and security tribes to join forces and turn
a more visionary and less parochial eye on this new century.
References
1. Brooks R. Thought cloud. Foreign Policy August 2, 2012.
http://www.foreignpolicy.com/articles/2012/08/02/thought_
cloud. Accessed May 20, 2013.
2. Holbrooke R. The Age of AIDS. PBS Frontline website. May
30, 2006. http://www.pbs.org/wgbh/pages/frontline/aids/
interviews/holbrooke.html. Accessed May 20, 2013.
3. Gellman B. AIDS is declared threat to security; White House
fears epidemic could destabilize world. Washington Post April
30, 2000;A01.
6
4. Berger SR. A foreign policy for the global age. Foreign Affairs
November/December 2000.
5. Annan KA. Problems without passports. Foreign Policy
September 1, 2002. http://www.foreignpolicy.com/articles/
2002/09/01/problems_without_passports. Accessed May 20,
2013.
6. UN High Commission for Refugees, Sadaka Ogata, Amartya, Sen. Human Security Now. 2003.
7. Brahmbatt M. Economic impacts of avian influenza propagation. Presentation to the First International Conference on
Avian Influenza in Humans; Institut Pasteur, Paris, France;
June 29, 2006. http://siteresources.worldbank.org/INTEAST
ASIAPACIFIC/Resources/Pasteur_Institute_Brahmbhatt_ppt.
pdf. Accessed May 20, 2013.
8. The White House. National Strategy for Biosurveillance. July
31, 2012. http://www.fda.gov/downloads/EmergencyPrepared
ness/MedicalCountermeasures/UCM314532.pdf. Accessed
May 20, 2013.
9. National Security and the Threat of Climate Change. Alexandria, VA: CNA Corporation; 2007. http://www.cna.org/
sites/default/files/news/FlipBooks/Climate%20Change%20
web/flipviewerxpress.html. Accessed May 20, 2013.
10. Frist WH. A Heart to Serve: The Passion to Bring Health,
Hope, and Healing. New York: Center Street; 2009.
Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science