Approaches to health security

The importance of health security in policy discourse has been acknowledged in the IR literature. In a recent survey, Colin McInnes and Kelley Lee included security as one of five fundamental ‘frames’ that shape existing understandings of global health – the others being evidence-based medicine, human rights, economism, and development.Footnote ⁷ Studies of global health governance have also recognised the importance of the security marker.Footnote ⁸ It has even been argued that security should be seen as a broad imaginary, with a long-standing social and cultural ancestry, shaping the way diseases are perceived and health policies are designed.Footnote ⁹

In fact, the IR engagement with health is inextricably linked with security. It originally developed out of a concern with the impact of diseases upon national security, particularly state stability and the preparedness of armed forces – a concern that speaks to the post-Cold War anxiety with ‘new’ and ‘emerging’ challenges.Footnote ¹⁰ Health issues have also been discussed from the standpoint of human security, that is, as threats to the welfare of individuals and groups.Footnote ¹¹ With the growth of securitisation theory, the status of health as a matter of security was subject to a more radical line of questioning.Footnote ¹² Instead of being concerned with the identification of health-related security threats, securitisation scholars turn to the processes through which health issues emerge as security problems, as well as to the political implications of this.Footnote ¹³ Securitisation-inspired studies thus place the emphasis on the ways in which actors represent health problems as threats to security. Reflecting the popularity of this approach, securitisation has arguably become the most prevalent framework in analyses of health security in IR.Footnote ¹⁴

Securitisation theory has enhanced our understanding of the health-security nexus. To begin with, it shows that this nexus is not self-evident. Diseases are not threats ‘out there’, waiting to be observed; rather, they emerge as such because of social processes of representation – which may be explicit or implicit, intentional or not. The framing of disease as a threat to security does not describe a reality, inasmuch as the register of ‘threat’ is involved in constituting the reality it purports to describe. A second contribution of securitisation is, therefore, that it allows us to see health security as a political modality for dealing with issues. Linking health with security is not only the result of a process; it also has an impact. When seen through the prism of securitisation, health security is thus conceived as a set of understandings and practices that shape political practice and the political realm more broadly, helping to justify certain policies and agendas, garner resources, or alter political priorities.

Nonetheless, there are drawbacks to this vision of health security. Securitisation theory has opened fruitful lines of enquiry but it has also foreclosed an engagement with important aspects. This is because this approach follows a restrictive reading of security as a political modality that brings with it dangerous or undesirable effects – a reading that harks back to a reluctance to conceive security as ‘a good to be spread to ever more sectors’.Footnote ¹⁵ For securitisation scholars, security has an overwhelmingly negative logic. It leads to issues being seen either as existential threats demanding exceptional measures or as technical questions. This, in turn, allows for normal democratic procedures, legal requirements, or international custom to be circumvented or reinterpreted.

This premise results in a pessimistic reading, inasmuch as the securitisation lens is particularly concerned with identifying the harmful results of ideas and practices of health security. Establishing a linkage between health and security – so this argument goes – makes it more likely that measures of containment, vigilance, exclusion, and even coercion are used to deal with health problems. Securitisation-inspired scholars thus tend to reject health security on the grounds of its political undesirability.Footnote ¹⁶ This sceptical view dovetails with charges put forward by authors writing from the standpoint of national security. For Susan Petersen, for example, health security brings no clear added value in both analytical and political terms.Footnote ¹⁷ She highlights the drawbacks of mobilising security when dealing with health issues like infectious diseases – namely that it may result in security dilemmas and create a competitive logic that hinders cooperation.

In general, then, it may be argued that the IR literature tends towards a deeply suspicious view of health security. This vision restricts the meaning of health security in at least two ways. First, it privileges the standpoint of the nation-state and of other powerful actors that are able to undertake securitising moves.Footnote ¹⁸ Second, it presents a deterministic reading of the political effects of health security, assuming that the latter necessarily entails unchecked measures or the sacrifice of rights and liberties. What is lacking is an appreciation of the different meanings that ‘being secure’ can have in the case of health. A government's concern with health security in relation to the preparedness of its armed forces in the face of infectious disease is different from that of a family without basic sanitation, or that of a person without access to affordable health care. For individuals, health security pertains to a life condition characterised by assuredness, predictability, or stability in relation to one's present and future status – and not to the ability to project force or maintain social cohesion. Different understandings of what health security means result in different ideas about what it may entail politically. Achieving health security does not necessarily imply restrictions upon democratic deliberation, the empowerment of an elite or forceful measures. It can actually mean the opposite: the broadening of democratic scrutiny upon health policymaking; a more participated debate about health provision; and a more solidaristic public sphere. The pessimistic reading of the assumptions and implications of health security may have become prevalent in the literature, but it is far from telling the whole story.Footnote ¹⁹

In order to do justice to the multiple facets of health security, one needs to go beyond the analyses available in the IR literature – be they inspired by securitisation theory or by more traditional, national security concerns. Ultimately, this entails questioning existing understandings of what security and insecurity might mean in the case of health. Seeking to shed light upon dimensions that so far have been neglected, the present argument advances an alternative approach to health security. This approach has two assumptions: firstly, the primary referent for thinking about security is the human being and not the nation-state. Therefore, in this article health security, and the lack thereof, refer to conditions experienced by individuals in context. The second assumption is connected: going beyond securitisation theory and its focus on social processes of representation, security and insecurity are approached as bodily experiences. Thinking about health security cannot be reduced to analysing securitising processes because people are and feel more or less assured about their present and future health regardless of whether problems are being securitised or not.

In addition to starting from these assumptions, the reconceptualisation suggested in this article is inspired by the idea that achieving security entails opening up space for individuals to make decisions and act in matters pertaining to their own lives. Individuals who are more secure are generally more able to influence in a meaningful way the course of their lives – free from social constraints like physical aggression, political persecution, poverty, or ill health, as well as from the broader structures and relations that make these constraints possible. Security is thus intrinsically connected with (context-specific) emancipatory politics.Footnote ²⁰ The idea of security as emancipation has the potential to offer fresh insights into the case of health, by shifting the focus towards the embodied reality of insecurity as a ‘life-determining condition’ of individuals.Footnote ²¹ The commitment to take insecurity – and not some a priori notion of security – as the starting-point is a novelty in the analysis of health. It distinguishes security as emancipation from other approaches in the IR literature – like national or human security – that assume that health threats derive in a self-evident way from pregiven definitions of security. Instead, for an emancipation-oriented approach, one should start from the bottom-up. Before considering what health security can mean, one must first unpack the meaning of insecurity.

Insecurity and domination

According to security as emancipation, the insecurity of individuals is to be prioritised and individuals may be considered insecure when they are prevented from freely determining their own lives.Footnote ²² However promising, this perspective still suffers from insufficient detail, so that realising its potential requires further theoretical work. In order to advance security as emancipation, and following the latter's injunction to take insecurity as a starting-point, this article develops an analytical lens for the study of concrete insecurities – that is, the situations one is to be emancipated from.

The concept of power – and, in particular, the notion of power as a form of domination – offers a useful lens with which to explore insecurity. Viewing power as domination is not the same as conceiving it in simplistic terms as a repressive or coercive force. Rather, domination is here understood as a multilayered concept that comprises, first, the shaping of action. In this ‘surface-level’ sense, power consists in the quality or property of an actor, which is wielded with the objective of shaping the actions of others by coercion or threat, by the delimitation of the field of acceptable and desirable action, and by foreclosing alternatives. This view of power is present in the work of Steven Lukes.Footnote ²³ For Lukes, power is not just as an overt intention leading to certain decisions or actions on the part of those affected. Power also operates by investing intentions with an aura of necessity or desirability, thus preventing dissent. Power is conceived as ‘the ability to constrain the choices of others, coercing them or securing their compliance, by impeding them from living as their own nature and judgment dictate’.Footnote ²⁴

Lukes's view dovetails with existing accounts of security as emancipation insofar as it is reliant upon the assumption that power works primarily via the imposition of constraints upon people's lives. The picture is, however, more complex than this. Michel Foucault and other authors working with the governmentality approach have advanced the idea of power as a productive force involved in the constitution of subjects.Footnote ²⁵ For these scholars, power consists in the mechanisms and strategies ‘shaping and governing the capacities, competences and wills of subjects’.Footnote ²⁶ Power should not be seen merely as a question of prohibition or repression because it can also denote the fostering of behaviours, tastes, and dispositions. Instead of defining subjects as mere recipients or targets of power – that is, as pregiven entities that are constrained in the free course of their lives – this view argues that subjects are also constituted, in their capacities and self-understandings, through power relations. As Foucault has put it:

The discussion of how subjects are constituted has often been framed in the governmentality literature by an understanding of power relations as essentially ‘horizontal’. Power – so this argument goes – does not simply emanate from the government or the sovereign ruler. Instead, power is something that circulates between nodes in society: hospitals, schools, churches, or civil society organisations. Individuals are not helpless targets, but rather conduits that always have the capacity to resist power to some extent. However important this horizontal element of power relations might be, it runs the risk of neglecting the hierarchical element that often permeates these relations. By stressing the relational nature of power/resistance, the view of power as constitution of subjects very often overlooks the fact that not all actors may be considered equally powerful.

Exploring how action is shaped and subjects are constituted should therefore be supplemented by a consideration of the ways in which power relations are sometimes skewed towards certain outcomes. This is why it is necessary to dig deeper into a third layer of power. The shaping of action and the constitution of subjects are embedded within a context in which unequal life conditions are structurally induced. Power relations occur in, and are themselves involved in the production of, an uneven field in which certain groups are systematically placed in a position of subordination in relation to others. Put differently, one of the components of power is a certain measure of domination.Footnote ²⁸

Domination can be defined as the systematic production of the privilege of some groups at the expense of others, via the exercise of arbitrary influence or as a result of existing rules in society. This means that decisions are made or effects are produced to the benefit of certain groups, without the constraint of effective rules or within a legal and institutional framework that fails to consider and protect the wellbeing of all affected parties. Dominated groups are thus vulnerable to decisions and outcomes with a high impact upon their lives, and which they cannot control or even predict. Domination entails an unequal relationship: the groups involved have different degrees of control over the relationship, so that some are systematically placed in a subordinate position. This does not necessarily entail the existence of a binary relationship between a dominated group and a consciously dominating one. As Jonathan Hearn has noted, strategic control is one possible face of domination, which can also occur via the sedimentation of advantageous positions, through (unintended) malign influence or by the sheer negligence of privileged groups or of those in positions of responsibility.Footnote ²⁹ Moreover, domination can occur at the level of behaviours (by directly shaping action); interests (by shaping what is seen as possible and desirable); and subjectivities (by shaping self-understandings and worldviews, which in turn impact upon interests).

Domination is a more comprehensive view of power than those currently available in security studies. Its main advantage is that it combines three approaches to power that, to a great extent, have been kept separate in this literature: power as the shaping of action (as in Lukes), power as constitution of subjects (as in Foucault), and power as the systematic production of privilege and subordination.Footnote ³⁰ Traditionally, security studies tended to read power as the property of a nation-state, and to assume that it entails the shaping of another state's behaviour via a combination of coercion and enticement, in the context of a struggle for the maximisation of utility.Footnote ³¹ The constitutive face of power is a concern shared by poststructuralists and some constructivists.Footnote ³² Feminist works have offered the most systematic engagements with the (gender-based) production of subordination.Footnote ³³ Domination succeeds in bringing these views together.

Therefore, when looking at issues from a security-as-emancipation perspective, the use of domination as an analytical lens allows for a more sophisticated investigation of insecurity. This lens sheds light upon the structural conditions that enable certain courses of action whilst constraining others, and that promote certain subjectivities as possible and desirable – in the context of an unequal playing field. This enhances our understanding of the shaping of action, by allowing us to consider the ways in which certain groups are made subordinate, and are thus prevented from deciding and acting in matters pertaining to their own lives. Furthermore, because it highlights the connection between structural conditions and accompanying processes of subject-formation, the lens of domination also allows us to go beyond a strict focus on external constraints. It paves the way for a consideration of individual perceptions and the processes through which subjects are constituted (or constituting themselves) as secure or insecure – perceptions and processes that, in turn, impact upon how insecurities are experienced. The lens of domination thus incorporates the view of power as constitution of subjects, and yet goes beyond it by drawing attention to the power inequalities that confront subjects at the moment of their constitution. Overall, then, with these features the lens of domination emerges as a particularly promising resource for the investigation of insecurity in the case of health.

Deepening and broadening health insecurity

It is important to emphasise that what is being suggested is not that domination is the true nature of health insecurity, or that the latter can simply be explained by tracing a causal link to domination. Rather, domination is here approached as a distinctive perspective that enables a more comprehensive engagement with insecurity, thus bringing to light facets so far neglected or insufficiently addressed in the IR literature.

What can domination bring to the analysis of health insecurity? To begin with, domination deepens analysis by allowing us discern different levels. Firstly, by highlighting the shaping of action and the constitution of subjects, domination underscores the subjective level of insecurity. This level refers to insecurities as they are experienced – both directly by those who live them and indirectly by those who acknowledge them. Secondly, by considering the social setting in which subjects are positioned and constituted, domination highlights the intersubjective level of insecurity. This level refers to the social processes that mediate subjective experience and that shape the perception and representation of issues as matters of security.

Thirdly, domination draws attention to the underlying conditions that enable or constrain individual experiences of insecurity and the ‘voicing’ and ‘listening’ of these experiences in the social sphere. This leads us to the structural level of insecurity, which refers to the material and ideational structures that confront actors as sedimented prior to their perceptions and interactions. Material entities – an infectious disease, for example – may affect our security regardless of what we think or say about them. Our knowledge about how these entities operate may provide us with tools with which to adapt; however, their existence imposes limits on what we can do. In addition, there are ideational entities – for instance, ideas and fears about disease transmission – that affect our experience of insecurity. Even though ideas are ultimately the result of human interaction, they cannot be simply wished away. Their existence and capacity to influence outcomes are not totally dependent on the consciousness and interaction of those specific individuals that are affected by them.Footnote ³⁴

In practical terms, this tells us that health insecurities do not derive self-evidently from the emergence of biological entities (such as a new virus strain) or from material conditions (such as poverty). At the same time, there is more to health insecurity than the (intersubjective) securitising moves through which certain problems are framed as threats. Finally, health insecurity is more than the reflection of subjective fears and experiences. Rather, health insecurity may be said to emerge from different combinations between the subjective, intersubjective, and structural levels. Anxieties regarding disease transmission illustrate some of the possible overlaps and disjunctures between these levels. The (subjective) fear of infection can express an individual anxiety or respond to a wider social unease, which in turn can be reproduced by the interplay of media accounts, government responses, and the interests of powerful actors like pharmaceutical companies (pandemic scares related to influenza strains are recent examples of this). This process may or may not speak to actual risks and vulnerabilities: consider, for instance, myths about disease transmission by hugging or using public toilets (HIV/AIDS, discussed in more detail below, has been a fertile ground for these panics). Moreover, in some situations actual risks and structural vulnerabilities are not translated into societal anxieties and into changes in behaviour (as evidenced by the case of noncommunicable ailments like cardiovascular disease, particularly in low- and middle-income countries).

Looking at the subjective, intersubjective, and structural faces of health insecurity is not the same as considering different ‘levels of analysis’ or ‘images’ in the Waltzian sense.Footnote ³⁵ Instead, what is envisaged is what Heikki Patomäki has termed ‘interpretive depth-explanations’.Footnote ³⁶ In these kinds of explanations, the analysis of particular issues is connected with an investigation of structural causality and agency. An awareness of structure and agency is important when analysing health insecurity inasmuch as it allows us to go beyond the descriptive stance of merely identifying threats in a top-down manner. It becomes possible to scrutinise the specific interactions between structures and agents in the reproduction or contestation of insecurities. In other words, the door is open for an exploration of how insecurities emerge, how agents interpret them, and what the possibilities are for overcoming them.

Thus, on the one hand, making sense of health insecurity requires an analysis of the ways in which structures – material entities and resources, institutions, or ideas – impact upon individual experiences of insecurity. They do so not necessarily by causing them in a direct ‘push and pull’ manner, but by functioning as enabling or constraining conditions of particular forms of subjectivity and action.Footnote ³⁷ On the other hand, these structures of insecurity are themselves reproduced through the practices of agents embedded in a network of structural possibilities and limitations. This means that structures can be challenged and even transformed by signifying practices and transformative struggles of agents acting in a social context. In sum, the lens of domination allows for agents and structures to be considered in conjunction, with their varying articulations reflecting different distributions and manifestations of power (and counter-power).Footnote ³⁸ This perspective enables a richer account of the conditions in which insecurities occur, and of the social processes through which they are reproduced and contested. Individual experiences of insecurity and ‘macrolevel’ dynamics in world politics can thus be tied more closely.

In addition to deepening, the lens of domination also broadens the remit of analysis, allowing for a nuanced appreciation of the meanings of insecurity in relation to health. At first glance, the health insecurity of individuals might simply be considered the actual or potential disruption of their wellbeing by an infirmity or by a change in the circumstances impacting upon such wellbeing. The lens of domination allows us to unpack this rather vague view of the meaning of health insecurity. It does so by revealing three ways in which insecurity can manifest itself. Each of these faces of insecurity includes not only actual threats, but also a dynamic element comprising ‘upstream’ conditions leading to actual insecurity and ‘downstream’ capacities for its transformation. This approach to health security builds upon Jonathan Wolff's argument that wellbeing depends not only on present states, but also on the ability to secure future states.Footnote ³⁹

Harm – an inflicted injury – is the first, and often the most visible, face of insecurity. Harm is more than the physical, coercive type: it also encompasses indirect or insidious injuries, not necessarily intended. Andrew Linklater has offered a typology of harm that includes psychological harm (for example, stigmatisation or humiliation); inadvertent harm (harm caused without the intention of causing suffering); negligent harm (resulting from the failure to take precautions to avoid harming others); exploitative harm (when groups profit unfairly at the expense of others); complicit harm (when groups are associated with institutions and practices that disadvantage others); omissive harm (harm caused by acts of omission); public harm (damage to institutions responsible for avoiding harm); and structural harm (when groups are affected by the rules and institutions in a society).Footnote ⁴⁰

This typology shows the different ways in which an individual's health may be adversely affected by material and ideational structures and by the social relations embedded in these structures. For example, in addition to the physical injury of disease an individual might suffer from the psychological harm of being stigmatised and segregated because of prevalent ideas and prejudices. The harm she suffers may be the result of a deliberate action (as in the release of a toxic agent) or inadvertent (the unintended transmission of a disease). Sometimes, this harm may be the result of negligence or omission on the part of those responsible for avoiding it (as in the case of industrial accidents stemming from unsafe conditions). Harm to health can also result from social relations that systematically place certain groups in harm's way so that others can benefit (for example, the case of miners exposed to fumes and radiation). Health can also be affected by damage being done to public health services, or by the rules and pay-walls determining access to healthcare.

These forms of health-related harm are insecurities because – going back to the notion of security as emancipation that inspires this article – they constitute impediments to the ability of individuals to make decisions and act in matters pertaining to their own lives. But they can also be recognised as insecurities when one considers their ‘upstream’ and ‘downstream’ elements. This is why the analysis of harm needs to be supplemented by an acknowledgment of existing vulnerability, that is, of a group's or an individual's susceptibility to harm.Footnote ⁴¹ In its most basic sense – that is, as the possibility of being harmed – vulnerability is an intrinsic part of being human because we are all connected to, exposed to and dependent upon others. Vulnerability may be considered a dimension of insecurity when it assumes a systematic character, that is, when certain groups are structurally positioned so that they are more prone or likely to being harmed. In addition to being an ‘upstream’ condition of susceptibility, vulnerability also encompasses a relative lack of capacity to ‘bounce back’ and overcome it.Footnote ⁴² This is because, in many cases, harm reinforces vulnerability. Take, for example, the case of uninsured individuals who see their lives disrupted by an accident requiring substantial medical bills, and who as a result end up with further vulnerabilities (such as homelessness).

The lens of domination reveals a second, interconnected face of health insecurity: unpredictability. Feeling and being secure requires certainty, that is, a set of stable expectations about what is likely to occur in the future, assuming that certain circumstances remain the same.Footnote ⁴³ In order to feel secure, individuals and groups rely upon a measure of predictability in their lives – which in turn cannot be separated from suitable conditions in society. Even though unexpected things happen, being able to reasonably expect that a given outcome will follow from certain circumstances is a fundamental condition of security. Being relatively assured about their surroundings allows individuals to make decisions and go about their lives without the constant fear of sudden disruption or even death. When lived in a situation of systematic unpredictability, individuals and groups are constantly placed at the threshold of survival – a permanent source of insecurity. The relevance of unpredictability when looking at health insecurity is illustrated by the case of the numerous individuals dependent on welfare provision and public health services. In times of austerity, with these safety nets being scaled back or eliminated altogether, life becomes extremely uncertain for many.

The ‘upstream’ and ‘downstream’ elements of unpredictability may be approached via the notion of lack of control. Chronically insecure individuals and groups normally have little control over their surroundings and little voice in decisions with a potentially harmful impact. They are inordinately affected by chains of events triggered by other actors’ actions and choices; and, to make things more complicated, these decisions are sometimes taken at a great spatial and temporal distance. Because their opinions and interests are seldom considered, they are frequently unable to predict the impact of these decisions. Their powerlessness and lack of control are perpetuated by the uncertain situation in which they find themselves, and which forces them to devote their time, energy, and resources to meeting the demands of survival.

The third face of health insecurity unveiled by domination is inequality. Inequality relates to a deep-seated discrepancy in the possession or access to different types of resources (economic, for example). It also relates to an imbalance in societal perceptions and self-understandings (ideas of racial superiority, for instance), which may condition access to and use of resources by some groups. Finally, inequality also relates to the relative weight of these resources in terms of actors’ capacity to influence outcomes. Whilst inequality relates to a set of relations already in place, the notion of disadvantage pertains to the likelihood that certain individuals and groups will find themselves in a position of inequality (the ‘upstream’ dimension). It also pertains to the possibilities for overcoming a situation of inequality or maintaining a more or less equal playing field (the ‘downstream’ dimension). Disadvantage very often translates as actual inequality, which in turn breeds further forms of disadvantage.

Inequality and disadvantage may be seen as faces of health insecurity because they place constraints upon the range of available options and opportunities. They do so by limiting access to the material resources needed for a healthy life-style, for instance, or by shaping subjectivities and self-perceptions in unequal ways, thus impacting upon some people's understandings of acceptable and desirable behaviour (one example is the unequal access to family planning and education, which leads to higher teenage pregnancy rates in some deprived sectors of the population). Moreover, inequality and disadvantage are also faces of insecurity because they interact with the two faces highlighted above: they leave subordinated individuals and groups in a position of greater vulnerability and lack of control over their surroundings. To a certain degree, harm, vulnerability, unpredictability, and lack of control are the result of fundamental inequalities. At the same time, this relation can be turned on its head, with disadvantage resulting from, or being perpetuated by, other insecurities.Footnote ⁴⁴

In sum, the lens of domination broadens the remit of analysis by allowing us to zoom in on the different ways in which health insecurity is connected with the (re)production of subordination. Domination reveals that insecurity also resides in particular articulations of structures and social relations that are systematically skewed towards the benefit of some at the expense of others. Those in a position of subordination see their life-chances curtailed because they are systematically vulnerable or harmed, unable to assert a degree of control or predictability over their lives, and/or chronically placed in positions of disadvantage and inequality.

With the simultaneously deeper and broader view afforded by the lens of domination, we are in a better position to unpack the abstract idea of health insecurity as a disruption of wellbeing. It becomes possible to approach health insecurity, not simply as the experience or threat of illness, but more comprehensively as a situation of domination through which life chances are constrained. Health issues can be considered matters of security if they restrict in a decisive manner the ability of those involved – individuals, families and/or groups – to shape the course of their lives, either by determining their action or by steering their conduct. This is not a question of the seriousness of the illness, but of its ability to impact upon the lives of those affected. For many people the simplest health problem can be a major constraint and even a watershed: someone in a precarious job, for example, may run the risk of being made redundant after calling in sick because of a flu or an upset stomach.

Health issues can also be seen as matters of security when they connect with broader political structures and relations. These go a long way in determining who is vulnerable to or harmed by disease, how systematically, and what opportunities and resources there are with which to deal with the occurrence of disease. When one is placed in a situation of disadvantage or inequality, it becomes more difficult – if not impossible – to have access to preventive measures, receive state-of-the-art treatment (and even any treatment at all), and benefit from compensation. When there is a situation of lack of control, one is unable to influence the external factors that condition exposure to illness; sometimes, this also entails the inability to recognise and predict the very factors that will affect one's health.

Finally, health issues are questions of security insofar as they may contribute to the reproduction of broader relations and structures of domination. By curtailing the ability of individuals and groups to make decisions and act in matters pertaining to their own lives, diseases reproduce disadvantage and actual inequality. Diseases may also reproduce systematic vulnerability and harm: for instance, incapacitating illnesses impact upon people's ability to work and to contribute to the subsistence of their households. Diseases may also increase one's lack of control over life and one's ability to adjust to exogenous shocks.

The value of health security

The approach to health security advanced in this article faces two sets of challenges. First, to what extent does it deliver fresh insights in the analysis of specific health problems? And second, what is the added value of mobilising security? Put differently, what does the vocabulary of security/insecurity tell us that other concepts – like development, human rights or equality – cannot? In order to tackle these challenges, the argument considers two illustrative examples: HIV/AIDS; and water and sanitation.