Evidence of harms in an authoritarian biosecurity response

As the pandemic unfolds, hindsight will provide more answers to these questions. Yet in a rapidly accelerating COVID-19 pandemic, there is already mounting evidence of decisions having been made in a centralised, hectic, top-down manner, constraining local choice even while demanding local flexibility and assuming responsiveness of communities and health systems.1 While regional reports suggest that stringent responses early in the pandemic were associated with a lower ensuing COVID-19 prevalence in some countries,5 longer term lockdowns, bans and quarantines raise challenges for already vulnerable groups in a range of countries and settings, with an accumulating health debt from loss of income, food insecurity, solitude and dying alone, mental health problems and discontinuity of preventive, promotive and curative care for other health conditions.1 This is particularly so when measures are prolonged, neglect lived realities, disproportionately target disadvantaged communities and do not provide adequate social protection.

Of significant, immediate concern is the militarisation and use of ‘war narratives’ that compare COVID-19 with a battle and relate the pandemic to being at war, referring to ‘the enemy’, with calls to ‘save the economy’ and essential workers labelled ‘frontline warriors’.6 Military capabilities can contribute in mobilising logistics and infrastructure. However, in many countries globally, state security forces and not public health workers or local law enforcement personnel have been deployed to communities to contain the spread of COVID-19.1 6–8 Military personnel deployed in communities respond to non-compliance with force, notwithstanding the difficulties that many, including migrant workers, street vendors, homeless people and others have with imposed measures.1 8 9 From diverse regions globally, there have been multiple reports of abuse by police or military power for curfew or lockdown violations, in terms of mass forced evictions, arrests, killing and deaths in custody.1 7 For instance, South Africa recorded 230 000 arrests and 11 deaths by security forces between March and April during its lockdown,7 and in recent months UN agencies report hundreds of thousands of people arrested for COVID-19 in a range of countries globally.1

Such militarised responses to COVID-19 are underpinned by a biosecurity-focused and authoritarian approach, with drastic and speedy impositions often carried out by security apparatuses that do not inform the public in a timely and transparent manner. This is comparable to the actions that governments take during wartime, ignoring the crucial role that an informed public can play in securing effective responses to public health threats. COVID-19 was declared a national emergency in many countries, following WHO’s naming COVID-19 as a Public Health Emergency of International Concern, as defined in the 2005 IHR. However, this has then been used to apply wide-ranging emergency laws and centralised executive power over local devolved action in different high, middle and low-income settings.9 Such actions have often been made without clear, relevant public information on the scientific justification or exit strategy, often without engaging local residents or their representatives and without consideration of the feasibility of measures, such as in demanding physical distancing in overcrowded slums.2 Private companies and governments have introduced the monitoring of people’s movements through satellite and mobile telephone platforms in many parts of the world, often using emergency powers to limit privacy and other rights.10 Such practices raise concern over how temporary, necessary and proportionate this surveillance is and of how the pandemic is being used to advance radical changes in how we interact with digital health technologies without considering the future implications of vast amounts of health data being stored by entities that are often not under public control.10

Military responses in global health signal the deeper legacy of both colonialism and coercive medicine, added to in recent decades by a perception in security agencies that epidemics pose a threat to economic interests and political stability.11 HIV and Ebola were both identified by the UN as threats to peace and security, and militaries deployed in communities in the 2014 Ebola outbreak in West Africa.11 A militarised biosecurity response is thus not unique to COVID-19. However, side-lining the expertise of health ministries, public health personnel and communities by locating the management of COVID-19 in centralised security sectors with weak public health experience fundamentally changes the nature of the response.8 It can divert resources to defence sectors or reactive, coercive and fear-promoting responses and away from the complex adaptive systems needed for effective and sustained public health interventions like test, trace and protect.8 The military response to the 2014–2016 Ebola epidemic in West Africa is estimated to have cost three times the amount that would have been needed to set up a well-functioning health system infrastructure.11

Militarised, overcentralised, biosecurity approaches undermine social cohesion and solidarity, encourage scapegoating and expand a pejorative discourse on migrants, refugees, minorities and others as ‘threats’ in the spread of the pandemic, enabling discrimination.12 This approach can reinforce a recent far-right, authoritarian and nationalist tendency in politics, associated with polarisation, populism and racism, playing out in different ways in different regions.13 Organising public health responses in this way can foment discrimination, even unwittingly, and undermine long-term social trust in the field.

In demanding obedience to command, rather than solidarity and informed action, and using criminal law to enforce behaviour change, these measures disempower and alienate communities from their central role in COVID-19 containment, paradoxically weakening adherence to behavioural measures.1 Technical biosecurity responses and incorrect learning from failures—including not learning from previous epidemics—risk undermining the values, rights and knowledge that effective public health depends on. Not listening to communities and front-line workers can lead to unworkable harsher restrictions on certain groups that contribute to widening inequality. For example, stay-home curfews deprive informal workers of livelihoods, while only higher income groups can take advantage of remote working or home schooling. Imposed measures and unclear, delayed and conflicting information build fear, anger, mistrust and mental health concerns and can drive social behaviours underground, making effective responses more difficult.1 8 Ignoring realities on the ground generates a growing health debt, as people with other conditions do not seek or get adequate care. Such responses potentially harm the relationship between communities and the state that contribute to public health, and exacerbate determinants of poor health, such as increased gender violence during lockdowns, prolonged exclusion of schooling, affecting mostly lower income children, and food and income insecurity.14 These consequences can undermine support for effective measures and can be highly counterproductive to containing a pandemic or its longer term health impacts.

Oversimplifying, scapegoating and restructuring public health responses have also shifted funds and institutional authority to large private, corporate actors and public health to national biosecurity institutions.15 16 Reorganising national public health bodies and selectively dismissing public health evidence without consulting experts and personnel can be wasteful, demoralising and counterproductive. While privatisation and commodification of public health systems are not new, the pandemic has provided an opportunity to intensify it in some settings, in contrast to approaches that coordinate private sector action under public sector leadership. Justifying these changes as necessary during an emergency places a smokescreen over the manner in which longer term austerity and privatisation may themselves undermine the opportunity for an effective public health response.16 Ignoring reminders from the WHO that the pandemic risk remains until all are protected, a sense of threat and self-protection has led to the inequitable stockpiling of essential health technologies and vaccine nationalism in high-income countries, undermining the international risk prevention and solidarity intended in the 2005 IHR.4 17 Emergency laws enabling a biosecurity approach have altered checks and balances on executives of government, enabling millions of dollars raised internationally or mobilised from public revenue to be applied without adequate parliamentary or public scrutiny, even while large sections of the population struggle to survive and face mental health crises with the loss of income under lockdowns.9

Advancing a comprehensive public health response

Biosecurity is not equal to public health. ‘Public health is the science and art of preventing disease, prolonging life and promoting health through the organized efforts of society’18 (p 2). It is implemented through participation, the organised efforts and informed choices of society, state and non-state organisations. It acts on the social determinants of health and health equity from proximal to structural levels, through the organisation of policies, services and social measures to ensure and improve the conditions and capacities for health and well-being for all. We cannot allow the response to COVID-19 to reduce public health in institutional practice and in the public mind to biosecurity alone, treating people as objects not agents, undermining knowledge, equity, rights and decades of prior work. We need to protect and advance a public health that is rooted in public interest and in the public; that is proactive, effective, participatory, principled, just, based on scientific and social evidence; that acts upstream on the social determinants of health and that builds cooperation between health, other sectors and communities and between countries globally.

Doing this starts with a different relationship with the local level and communities, as a matter of rights and justice and for public health effectiveness. Local organisation, health literacy, local leadership, ideas, innovations and action are all necessary to prevent infection and provide social protection and care. They are core for an effective public health response.1 2 17 There are many examples of affirmative community involvement in the response to COVID-19 from all regions globally.1 19–21 They show alternatives in social action and collaborations between communities and states that contrast with inappropriate and overcentralised biosecurity responses. As we enter the sixth month of the declaration of this pandemic, we would do better to dialogue, work with and respect the public and diverse professionals, sharing knowledge and information to understand and act on risk.

We need to protect an ethical, scientific and rights-based approach to public health, such as the UN Siracusa principles shown in box 1.22

Like all rights-based approaches, such principles come alive when known, implemented and upheld by all in a manner that builds collective power, rather than dominating power. The principles are subject to interpretation. Decisions made in the ‘public good’ need, therefore, to be probed for the technical knowledge, evidence, consultation and sociopolitical interests and power that inform them and the measures included for accountability and learning from action. The evidence applied needs to include the full range of systematically organised knowledge, including from implementers and from communities’ lived experiences. In contrast to a self-protective response, health as a human right needs to be understood and implemented as a collective responsibility, within countries and globally.1

‘Health actors, community leaders and communities must co-construct options for COVID-19 response that are acceptable, and feasible, and foster commitment of affected communities’21 (p 2). In part, doing this implies proactive design of measures through decentralised governance and deeper, more nuanced engagement with local health and social service professionals, local authorities, civil society organisations and different social groups, including marginalised communities and youth. This type of engagement helps to interpret and locally adapt guidance to effectively implement key responses, including testing, tracing and protecting people; preventing and controlling outbreaks and supporting vulnerable groups. It also calls for significantly better, honest communication in appropriate messages for diverse needs, with health literacy outreach to build informed action and accountability. It calls for timely warning of outbreak control measures and of support and exit strategies. It demands explicit attention to equity, non-discrimination and to implementing public health measures in ways that build trust and combat stigma, racism and xenophobia. We do not have a blank slate on this. We have drawn learning from the response to HIV, where those affected themselves challenged silence, neglect and stigma and cocreated collaborative action; from ‘bottom-up’ responses to Ebola in Africa1 21 and from the many positive experiences in the responses emerging to COVID-19 noted earlier that provide valuable learning for public health.1 17 19 20

Conclusion: Choosing a comprehensive, participatory public health approach

COVID-19 will be with us for the longer term. It will not be the last pandemic. We do not need to and should not coerce, terrify, fatigue, undermine and harm public trust and public health systems in our response. We need a public health response that generates communication, understanding, learning, capabilities, civil responsibility, local innovations and global solidarity. COVID-19 has stimulated an extraordinary mobilisation of response in a short time. It provides an opportunity to learn, reflect on and build an effective form of public health to meet a 21st century that is facing multiple crises including future pandemics, climate, food, energy, precarious labour, grotesque and growing social inequality, conflict and other threats. In as much as there has been a historical trend towards centralised, authoritarian biosecurity responses, there have also been contesting movements towards a comprehensive, social determinant, participatory and justice-driven public health, in different regions and countries and globally. Let us reclaim, support, invest in and implement this latter version of public health.