Medicine at the Border: Disease, Globalization and Security, 1850 to the Present

Alison Bashford's latest edited collection, Medicine at the Border: Disease, Globalization, and Security, 1850 to the Present, brings together papers from a 2004 conference on the same broad topic. Like many conference volumes, this one both benefits from its origins in face-to-face discussions across disciplinary boundaries, and suffers somewhat from the fact that such conversations rarely survive the transition into print. The thirteen chapters which comprise Medicine at the Border are divided into three thematic sections: 'World health: global and national histories', 'National security: migration, territory, and border regulation' and 'Globalization: deterritorialized health'. Although these divisions do, as their titles suggest, weight the sections towards particular approaches, Bashford is to be commended as an editor for not simply dividing the book along disciplinary lines. Historians are grouped with sociologists, public health scholars with specialists in law, and geographers with just about everybody. Thus, even though few of the book's authors seized the opportunity presented by this collection to generate interdisciplinary discussions across the chapters, the structure of the volume makes it easy for readers to do so themselves. In this regard, Bashford's introductory chapter, 'Age of universal contagion', is a real boon for the reader, as she effectively and gracefully draws out the linkages between the book's three sections, and 12 other chapters.

Bashford's chapter also offers a valuable overview of what she sees as a movement from absolute to relative measures of border health control, paralleled by a movement from 'territory-oriented' to 'network-oriented technologies', and by the 'intertwining' of the national, the colonial and the global. She argues that studies of world health must be embedded into world history, and portrays infectious disease as being 'central to the political, legal, and commercial history of nationalism, colonialism and internationalism, as well as to the twentieth century invention of a newly imagined space for regulation called "the world"' (p. 1). Moreover, Bashford suggests that today's links between aid, politics, development, commerce and 'disease management' have deep historical roots, and did not emerge de novo from postcolonial complexities. Practices at borders - however those borders are defined and located - show strong continuities across the period. Quarantine and the medicalised screening of migrants, trade barriers, isolation of carriers, targeted vaccination - all are still in use. And in this century as in the two preceding it, disease is used to justify both formal and, crucially, informal interventions across borders. This is not to say that Bashford ignores changes in border policing and surveillance. She notes the rise of supranational surveillance, 'defensive' nationalism, and the emergence of particular kinds of information networks. Bashford, and this volume as a whole, makes a strong case against claims of a lost colonial past of hygienic security. Instead, Bashford and her contributors demonstrate the considerable and growing power now invested in the mechanisms of global public health. In the chapters which follow, authors contest the origins, mechanisms, efficacy and impact of that power - but all share a sense of its presence and position at the centre of the nexus joining commerce, culture, security and health.

In the historical chapters which dominate the book's first section, authors discuss the emergence and impact of 'medical internationalism' and its relationship with colonisation, decolonisation, eradicationism and global health governance. Patrick Zylberman, in 'Civilising the state: borders, weak states, and international health in modern Europe', compares European responses to Muslim pilgrimage and associated cholera outbreaks in the declining years of the Ottoman Empire with responses to malaria in Macedonia and the 'sanitary zone' in Eastern Poland after the First World War. Looking at international sanitary conferences and other international health forums, he describes a perceived right of nations to make 'pre-emptive interventions' on the grounds of public health and portrays modern health institutions 'spreading inward from the borders rather than outward from the centre' (p. 21). His is the first of many examples in this volume of the presumption on the part of the developed world that the 'defence of health' (p. 29) would be enacted elsewhere.

In 'Yellow fever crusade: US colonialism, tropical medicine and the international politics of mosquito control, 1900-1920', Alexandra Minna Stern turns from Europe to the US, and from the Suez to the Panama Canal, to build her analysis of the racial underpinnings - the 'ugly underbelly' (p. 51) - of colonial and tropical medicine, and the conjoined US military and sanitary interventions in central and south America. Although the story, one of the conflation of racial differences, disease propensities and vulnerable locales, will be familiar to scholars of colonial and tropical medicine, it is well told, and Stern's setting and her examination of US, rather than UK or European, empire-building valuably extends the literature. Immediately following Stern's lively chapter, Sanjoy Battacharya's account of complexity and tension between national and international actors and agencies promoting smallpox eradication in India (entitled 'WHO-led or WHO-managed? Re-assessing the smallpox eradication program in India, 1960-1980') does exactly what it says on the tin. Although his material will hold few surprises for scholars of such co-operative endeavours, the essay is still a useful corrective to conventional valedictory accounts of the campaign. It is slightly unfortunate that Battacharya, unlike Stern, so rarely allows his historical actors to speak in their own voices - which somewhat obscures the very dynamic tensions he intends to document.

While these first three chapters look closely at specific historical examples of international health activities, the fourth, Theodore Brown, Marcos Cueto and Elizabeth Fee's 'The World Health Organisation and the transition from "international" to "global" health', takes a slightly different approach. They analyse the language of public health through the lens of the World Health Organisation's own history. They find beneath the shift from 'international' to 'global' a movement away from the co-ordination between sovereign nations of efforts strictly constrained by national borders towards the trans-national co-ordination of efforts across boundaries, reflecting new models of social, political and economic interdependence. Brown, Cueto and Fee sketch out a number of antecedents for this shift, from the return the Soviet Union to the World Health Authority (leading to a revived concern with primary care and immunisation) to the entrance of the World Bank (with its equally ideological emphasis on private sector provision) into healthcare development. Most interestingly, they demonstrate the ways in which the WHO took advantage of this shift to renew its mission and credibility, and to parlay its existing and acknowledged expertise in the provision of health services into a leadership role centred around the new paradigm of 'global health'.

Medicine at the Border's second section builds on these historical foundations, opening with another three-hander from geographer Ian Covery, health researcher/historian John Welshman and Bashford herself. 'Where is the border? Screening for tuberculosis in the United Kingdom and Australia, 1950-2000' is the only fully-fledged example of comparative history in the volume, and seeks to define 'otherness', 'borders' and the work done by them. Overall, it presents an argument for British exceptionalism from the norm of colony nations, with their legacy of interwoven health and immigration laws. Comparing what they posit is the UK's diffuse internal health border with Australia's rigid and strictly policed external one, the authors argue for the persistence of aspects of 'coloniality' in each nation. While the comparison is highly suggestive, and the piece makes intriguing links between contemporary debates and their recent historical antecedents, it suffers from an emphasis on describing the UK's unusual approach to screening, rather than assessing why that approach emerged and persisted.

Miriam Ticktin, too, is concerned with exceptionalism - this time French - in her chapter, 'Medical humanitarianism in and beyond France: breaking down or patrolling borders'. Rooted in France's historical concern with universalism - and with the concepts of duties, rights and responsibilities packed into the polysemic 'le droit' - 'medical humanitarianism' was pioneered in France by the professional group Médecins Sans Frontières. These concepts also inform France's 'illness clause', under which sickness and dependence endow rather than revoke the right to remain in France. Ticktin argues that both of these examples of medical humanitarianism emerge from the contradictions of France's interventionist colonial history and represent a new 'mission civilatrice' (p. 122), and interrogates the boundaries both of such medical humanitarianism and of the limited civic status it creates. This is an elegant piece of thinking, and begs for use as a comparator to other national responses.

Renisa Mawani's chapter on mandatory HIV screening for immigrants to Canada offers exactly such a comparison, describing an alternative national approach to the need for modern and liberal border health controls. With its cherished self-perception as an inclusive and tolerant nation at stake, Canada had much to lose when it re-wrote its immigration laws in the early years of the 21st century. The decision to include mandatory HIV screening, in particular, demanded careful handling. In 'Screening out diseased bodies: immigration, mandatory HIV testing and the making of a healthy Canada' Mawani demonstrates the persistence of the racially discriminatory effects of health screening measures, despite strenuous efforts to craft a visibly race-neutral policy to protect robustly Canada's commercial interests and its 'overstretched' universal healthcare system. Noting the resistance of politicians to addressing, or even admitting such racist effects, she argues that this 'is hardly surprising, given that liberalism's response to racism at best fails to take it seriously and at worst denies racism altogether' (p. 153). This chapter can also be read usefully in parallel with the volume's two chapters on SARS in Canada (described below).

Richard Coker and Alan Ingram, in their article 'Passports and pestilence: migration, security, and contemporary border control of infectious disease', address similar themes, stating particularly clearly the relationship between mechanisms of health control and the construction of stable national identities and borders. Their chapter thus builds nicely on those which precede it in the volume, echoing in particular ideas found in Zylberman. But they also draw a salient distinction between border-policing responses to chronic, as opposed to acute infectious conditions. Given the attention historians of medicine pay to chronicity as a defining characteristic of disease in the developed world, it is ironic that only this chapter, written by two geographers, really tackles the issue. Coker and Ingram also return to the matter of UK exceptionalism, this time in relation to the UK policy of separating development and security (though there are clear parallels between their account of UK responses to HIV/AIDS and TB - offering development aid to treat the diseases abroad, while seeking to limit access to free treatment at home - and those detailed by Mawani in Canada).

In the book's final section, 'Globalization: deterritorialized health', Bashford's authors explore 'supranational' public health and the surveillance of health and disease independent of territorial borders or physical locations. Two authors focus closely on the SARS outbreak, particularly in Canada. Claire Hooker, whose chapter 'Drawing the lines: danger and risk in the age of SARS' opens the section, argues that the 20th-century shift from notions of 'dangerousness' to models of 'risk' in health-policy making was challenged by SARS. Responses to the outbreak - and the fear it provoked - demonstrated a reversion from health promotion and population surveillance to older techniques of quarantine, isolation, sanitation and the surveillance of individuals. SARS lacked easily identifiable 'at-risk' groups (and included economically desirable business travellers and tourists among its vectors); Hooker argues that the experience of this new threat created a 'new normal' in which the demands of national 'preparedness' trumped calls for 'the renewal of public health' - but also amplified the need for certain kinds of 'global health governance' (all p. 192). Carolyn Strange deepens and extends Hooker's analysis by looking at the impact of SARS as an 'Asian' disease on the multicultural western city of Toronto. Her chapter, 'Postcard from plaguetown: SARS and the exoticization of Toronto', is among the most revealing (and easy to read) in the volume. Strange illustrates the ease with which western institutions and individuals reinstated the old 19th-century link between the Chinese diaspora and disease. Side-by-side with this, she documents the shock and anger with which Torontonians responded to being themselves exoticized by the presence of illness, and at the hands of a global institution (the WHO) and the global media. Finally, Strange narrates Toronto's efforts to rebuild its reputation as a clean, but also as a diverse and tolerant city, and the ironic role of exoticism in that 'rebranding' process.

The remaining two chapters look more generally at responses to SARS and to the type of global threat - to health and to national security - that SARS came to represent. David Fidler, in 'Biosecurity: friend or foe for public health governance', uses SARS to explore a 'transformational moment in public health as a governance activity': the rise of 'biosecurity' (p. 196). After a useful, if necessarily brief summary of the history of biological weapons, and of the term 'biosecurity', Fidler asserts that the timing of SARS led to a conflation of bioterrorism, terrorism and epidemic disease. This conflation spawned a new and expensive 'preparedness' imperative that risks swamping public health priorities. More positively, Fidler notes, the new interrelatedness of health and security has elevated public health to being 'an independent marker of good governance' (p. 216).

Finally, in 'The geopolitics of global public health surveillance in the twenty-first century', sociologists Lorna Weir and Eric Mykhalovskiy discuss the emergence of the Global Public Health Intelligence Network (GPHIN), which uses global news rather than national public health epidemiological sources to track diseases and pinpoint outbreaks. GPHIN effectively bypassed sovereignty and national control, speeding and expanding the flow of information about global disease outbreaks - but its information could only be productively deployed by an accepted and accredited actor in the sphere of global health: the WHO. Initially a partnership between GPHIN and the WHO allowed the latter to apply transnational leverage when national public health bodies (as, for example, in China in the early stages of the SARS outbreak) were reluctant to co-operate. However, when GPHIN expanded its coverage to (commercially saleable) 'intelligence' matters, the WHO was forced to distance itself - to become a client, rather than a partner - to maintain its neutrality and thus credibility. Weir and Mykhalovskiy contrast GPHIN with the 'securitized' process of 'syndromic surveillance' - another but rather less effective or broadly applicable way to get information about population health and disease foci in the absence of 'Westphalian' governmental reporting and diagnosis. Like Fidler, Weir and Mykhalovskiy foreground the impact of fear and security on global public health surveillance. Both chapters demonstrate that the new relationship between health and security can enhance, as well as detract from more conventional public health endeavours. And both also show that the nation, like the national health border, has not yet disappeared from the sphere of public health, despite new global approaches and concerns.

Without denying or erasing the changes that have taken place in public health and border medicine over the course of the 20th and 21st centuries, Medicine at the Border: Disease, Globalization and Security, 1850 to the Present thus closes the circle, and finds a balance between documenting the distinctive features of contemporary medicalized borders and reminding scholars and policy-makers alike that they have deep roots and unintended consequences we cannot afford to ignore.