Economy and Society

ISSN: 0308-5147 (Print) 1469-5766 (Online) Journal homepage: https://www.tandfonline.com/loi/reso20

Real-time biopolitics: the actuary and the sentinel

in global public health

Andrew Lakoff

To cite this article: Andrew Lakoff (2015) Real-time biopolitics: the actuary and the sentinel in
global public health, Economy and Society, 44:1, 40-59, DOI: 10.1080/03085147.2014.983833

To link to this article: https://doi.org/10.1080/03085147.2014.983833

Published online: 03 Feb 2015.

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Economy and Society Volume 44 Number 1 February 2015: 40–59
http://dx.doi.org/10.1080/03085147.2014.983833

Real-time biopolitics: the

actuary and the sentinel in
global public health

Andrew Lakoff

Abstract

This paper analyses the mechanisms through which experts in the field of global
health work to manage the future well-being of populations. It develops a
contrast between two ways of approaching disease threats: actuarial and sentinel
devices. If actuarial devices seek to map disease over time and across populations
in order to gauge and mitigate risk, sentinel devices treat unprecedented diseases
that cannot be mapped over time, but can only be anticipated and prepared for.
The paper shows that a recent controversy over vaccination in Europe in
response to the H1N1 pandemic can be understood in terms of the tension
between these two kinds of security mechanisms.

Keywords: biopolitics; governmentality; global health; security; influenza;

vaccination.

Over the past three decades we have witnessed the appearance of a new
governmental problem in public health: how to manage ‘emerging infectious
diseases’ at a global scale. Examples of such emerging infections include
weaponized small-pox, mad cow disease (BSE), extremely drug-resistant
tuberculosis (XDR-TB), and bird flu (influenza A/H5N1). While diverse in
their origin, prevalence and biological characteristics, these diseases share several
features: first, they are understood to have arisen as a result of intensifying
modernization processes – whether ecological incursions, biotechnical manip-
ulation, agricultural industrialization or increased global circulation. Second,

Andrew Lakoff, Department of Sociology, University of Southern California, Los Angeles,

CA 90089, USA. E-mail: andrewlakoff@gmail.com

Copyright © 2015 Taylor & Francis

 Andrew Lakoff: Real-time biopolitics 41

since these pathogens have not previously appeared, the risk they pose is not
calculable using traditional tools of risk assessment, which are based on patterns
of historical incidence. And third, these emerging infectious diseases are not
readily manageable using the existing tools of national public health and medical
systems, and so threaten global populations – and economies – with catastrophe.
For these reasons, the threat of emerging disease poses novel challenges for
the political administration of collective life. From the vantage of jurisdiction,
it raises the question of what agencies and experts are to be charged with
monitoring and responding to emerging pathogenic threats. And in terms of
veridiction, it points to the problem of how to know that a potentially
catastrophic outbreak is imminent. This paper suggests that the framework of
biopolitics, as introduced by Michel Foucault in his writings and lectures of
the late 1970s, offers conceptual tools for understanding the significance of this
new problematization of disease for the contemporary government of life.
The paper proceeds in three parts. The first part summarizes the conceptual
approach for thinking about the government of disease developed by Foucault
in the early lectures of his 1978 course on security, territory and population. In
particular, it points to the illuminative contrast he draws between disciplinary
techniques and security mechanisms as distinctive approaches to the same
apparent ‘problem’. Following the approach outlined in these lectures, the
paper proposes to distinguish between risk management and vigilance as two
kinds of security mechanisms. The second part of the paper examines how a
norm of vigilance, as embedded in sentinel devices, structures certain areas of
global public health – and, in turn, the ways that actors who are invested in a
different form criticize this mode of action. Here the paper follows a recent
European controversy around vaccination policy that – while it played out in
an ‘ethical’ idiom – is better understood as a challenge to the legitimacy of the
sentinel device as a guide to techno-political intervention. The third part
addresses the question of how vigilance became a significant modality for
governing infectious disease, tracing the recent history of global public health
security as a key site for the invention and dissemination of sentinel devices. As
an apparatus of vigilance, global public health security structures the action of
government officials when faced with responsibility for decisions about an
uncertain but potentially catastrophic event.

Risk management and vigilance

In his 1976 introduction to The history of sexuality, Michel Foucault provided a

provocative, if opaque formulation, of the domain of inquiry named by the
term biopolitics: ‘For millennia’, he wrote, ‘man remained what he was for
Aristotle: a living animal with the additional capacity for a political existence;
modern man is an animal whose politics places his existence as a living being in
question’ (Foucault, 1976, p. 143). This formulation raised a number of
questions: What is this new form of politics that centres on man as a living
42 Economy and Society

being? What are its aims, its objects and its regulative principles? Such
questions occupied Foucault for the next several years, in his lectures at the
College de France between 1976 and 1979. A partial response, based on his
approach in these lectures, is that this new form of politics is a techno-politics:
a politics of devices or apparatuses, typically designed by little-known
government planners, that make it possible systematically to gather knowledge
about humans as living beings, and to implement targeted interventions with
the aim of increasing the well-being of populations.
The 1978 lectures on ‘Security, territory and population’ focus on the
period in which the problem of population initially appeared as a central object
for governmental knowledge and intervention: the late eighteenth and early
nineteenth centuries. Here Foucault is particularly interested in characterizing
the operations of what he calls ‘security mechanisms’. To illustrate how
security mechanisms work, he makes a series of contrasts with disciplinary
mechanisms.1 These schematic comparisons describe how each type of
apparatus treats a given problem-space: the town, scarcity and disease.
One of the suggestions Foucault makes here – though it remains somewhat
implicit – is that security mechanisms arose at an historical moment in which
disciplinary methods reached a limit of effectiveness: a technology of power
that sought total control proved insufficient for dealing with a novel set of
economic and social challenges linked to the integration of the town into
existing structures of legitimate sovereignty.2 In contrast to the restrictive and
centralizing power of discipline, liberalism was articulated as an ‘art of
government’ that emphasized the free circulation of men and things, and
which depended for its efficacy on mechanisms of security that could ensure
the optimal regulation of such flows.
For the purposes of this paper, it is useful to look in more detail at
Foucault’s discussion, in the third lecture, of how each type of apparatus treats
disease. If disciplinary mechanisms seek to restrict the circulation of disease,
isolating the sick from the healthy – as in quarantine – security mechanisms
allow disease to circulate but minimize its damage through collective
interventions such as mass vaccination. Detailed knowledge of patterns of
disease incidence among a given population over a certain period of time is
necessary in order to measure the efficacy of security mechanisms. Thus, early
advocates of inoculation conducted statistical analyses of small-pox mortality
rates and of the efficacy of variolization. Such analyses, Foucault argues, led to
a series of transformations in the meaning of small-pox. First, through
quantitative analysis of incidence, the disease appeared no longer as an overall
relationship between a disease and a place or people, but ‘as a distribution of
cases in a population circumscribed in time or space’ (Foucault, 2007, p. 60).
Second, the analysis of the distribution of cases in a population made it
possible to calculate the risk, for an individual or a specific group, of
contracting the disease and dying from it: if one knew the age, town, or
profession of a given person, one could determine the risk of morbidity and of
mortality. Third, such risk calculation pointed to zones of particular danger: it
 Andrew Lakoff: Real-time biopolitics 43

was more dangerous to be under three years old than to be older; it was more
dangerous to live in a town than in the countryside. And finally, through this
lens of the statistical calculation of risk, the occurrence of crises – the sudden
acceleration of the disease – became visible as a regular phenomenon.
This taking up of the entire population, rather than simply dividing the sick
from the healthy, in terms of its relative probability of mortality is
characteristic of the operations of a security apparatus, according to Foucault.
Once sufficient data has been gathered on differential rates of mortality, it
becomes possible to develop targeted interventions that will reduce the
occurrence of disease to a more optimal level, though not completely eliminate
the disease: for example, one can focus on lowering the heightened risk of
childhood mortality to that of the overall population.
The early history of public health involves the gradual implementation,
within governmental practice, of this style of reasoning about disease risk.
Beginning in the early nineteenth century, as Ian Hacking has documented,
national governments began to publish massive amounts of statistical data on
the vital characteristics of populations: their rates of marriage, birth, death and
disease.3 The analysis of the data revealed that while the future was contingent,
there were nonetheless certain regularities according to which governments
could rationally plan. This mode of calculation became the standard for
policies addressing collective risk, in arenas ranging from public health, to
industrial accidents, to retirement pensions (Ewald, 1991). From within this
actuarial logic, the demonstration of such calculation was necessary in order to
render political decisions concerning future risk legitimate, whether or not the
potential hazard eventually appeared.4

Actuarial devices

A classic early instance of the accumulation of vital statistics as a means to guide

public health policy is Edwin Chadwick’s 1842 Report of an inquiry into the
sanitary conditions of the labouring populations of Great Britain. The Report
aggregated the number of deaths from various diseases in London in the prior
year and assumed that the accumulation of data about past patterns of incidence
would generate actionable knowledge about what was likely to occur in the
future. This was the basis of a cost–benefit argument in public health: one could
make a rational case for a given intervention if one could demonstrate its worth
through a statistical analysis. Thus Chadwick’s investigation sought quantita-
tively to demonstrate that the economic benefits of improving the health
conditions of poor populations would outweigh the costs of such measures: ‘the
expenditures necessary to the adoption and maintenance of measures of
prevention would ultimately amount to less than the cost of disease now
constantly expended’, concluded the Report (cited in Rosen, 1993, p. 187).
Such an approach to disease risk can be termed ‘actuarial’. Like insurance, it
requires historical data on patterns of incidence of events in order to make
44 Economy and Society

rational calculations about future probabilities. However, it applies these

methods with a different aim: to reveal the laws of human vitality, demon-
strating that events that appear to be contingent at the individual level in fact
correspond with regularities at the level of the collective. Assembling such
data, nineteenth-century European public health administrators began to
design and implement actuarial devices to gauge the health of urban
populations. For example, the ‘life table’ or ‘biometer’ invented in the 1840s
by William Farr, head of the British General Register Office, demonstrated the
likelihood of death in any year for each member of a particular age group.5
Farr’s biometer combined national census data with parish death registers,
tracking a group of infants born at the same time through life, and recording
the numbers still alive at periodic intervals until all had died. Such data could
then point to regularities of collective life that would enable government
planners to anticipate the future. Thus, with a biometer one could calculate the
average life expectancy for all children born in 1841. As Farr put it: ‘Although
we know little the labours, the privations, the happiness or misery, the calms or
tempests, which are prepared for the next generation of Europeans, we
entertain little doubt that about 9,000 of them will be found alive at the distant
Census in 1921’ (cited in Eyler, 1979, p. 73). In the service of contributing to
rational future planning, actuarial devices like the biometer demonstrated the
law-like regularities underlying seemingly contingent vital phenomena such as
birth and mortality.
Such devices could also reveal anomalies in rates of death and illness that
pointed to potential targets of intervention, as we saw above in Foucault’s
description of the calculation of small-pox risk according to age. In his research
on the 1848 cholera outbreak in London, Farr analysed the course of the
epidemic numerically, building a ‘sickness table’ order to determine the
probability of recovery or death for each victim of the disease. As historian
John Eyler (1979, p. 69) describes the method, ‘he applied some of the
actuary’s basic techniques to problems in medicine, public health and
economics’. One such table indicated that the risk one faced of dying from
cholera in the 1848 London epidemic was related to the elevation of one’s
residence; Farr hoped this evidence would help demonstrate his miasmatic
theory of disease causation.
The impact of social and environmental factors on life chances became
knowable through the accumulation of vital statistics in actuarial devices.
Thus, French social reformer Luis René Villermé assembled tax data together
with death records to analyse the effects of housing conditions on comparative
mortality rates during the 1832 cholera epidemic in Paris. His research
demonstrated conclusively that ‘death is a social disease’, as historian William
Coleman (1982) put it: in other words, that social class corresponded in a
regular fashion with susceptibility to the epidemic.6 Thus by the mid-
nineteenth century, the relation of social conditions of living such as poverty
and class to collective vitality became visible to political reflection through the
accumulation and publication of statistical data on the health of populations.
 Andrew Lakoff: Real-time biopolitics 45

Sentinel devices

The actuarial style of reasoning, oriented towards disease prevention through

the calculative management of risk, has remained predominant among experts
in public health up to the present. However, beginning in the last decades of
the twentieth century it has increasingly coexisted with a different approach to
threat, one that emphasizes vigilant monitoring of the onset of an unpredict-
able but potentially catastrophic event. Sociologists Francis Chateauraynaud
and Didier Torny (2005) have analysed risk management and vigilance as
distinctive technocratic approaches to potentially dangerous future events. Risk
management, they argue, involves the creation of a common space of
calculation through which planners can predict the likelihood of future events;
whereas vigilance, in contrast, assumes that the future cannot be known and
that one must therefore be prepared for surprise. Rather than pointing towards
a cost–benefit calculus to guide decisions on intervention, vigilance enjoins
action in a precautionary mode: one must act now to interrupt the onset of a
potential event or be held accountable later for the results of inaction.7 For a
decision-maker faced with possible future catastrophe, they note, ‘it is no
longer possible to say, without exposing oneself to criticism, that “according to
the calculations, the risk is negligible”’ (Chateauraynaud & Torny, 2005, p. 4).
Returning to the formulation above: two types of security mechanism are at
play here. If risk management leads to the invention of actuarial devices that
assemble patterns of historical incidence in order to calculate the probable
future, vigilance requires sentinel devices that can provide early warning of an
encroaching danger. An actuarial device is invented for a world in which the
possible threats to collective life can be known through careful demographic
and epidemiological research; the problem is one of accumulating statistical
knowledge to guide cost-effective intervention. A sentinel device, in contrast,
is devised in order to stimulate action when decision is imperative but
knowledge is incomplete.
In a number of contemporary arenas in which future crisis looms, one finds
a proliferation of sentinel devices. These devices are especially salient for
experts in monitoring threats whose onset may be sudden and unpredictable,
and which may initially be imperceptible to humans, but whose occurrence
portends catastrophe. One can take as an example the tracking of animal
populations, such as polar bears or bee colonies, whose decline warns of
potential ecological collapse (Benson, 2010; Silverman, 2013), or the practice of
monitoring avian influenza among migratory birds as heralds of a potential
human pandemic (Keck, 2010). In the field of global health security, such tools
are designed to detect the emergence of unexpected or previously unknown
pathogens. Examples include global ‘viral forecasting’ efforts, such as a
Google-funded enterprise run by a biological anthropologist to test African
bush meat for new zoonotic diseases, based on the premise that such a system
will help to ‘stop the next pandemic before it starts’ (Lachenal, 2015),
and syndromic disease surveillance systems, which aim to detect signals that a
46 Economy and Society

new disease is afflicting the population even before doctors have made a
diagnosis – for instance by looking for anomalies in the number of emergency
room visits in a given period or in the use of over-the-counter medications
(Fearnley, 2008).
While such devices are designed to alert officials to a significant event as it
unfolds in the present, they typically provide little information about what is
likely to happen next and do not themselves trigger an intervention. For this
reason, they are typically linked to guidelines or protocols for taking authorized
action in the face of uncertainty. As we will see below, the already-formulated
emergency protocol makes it possible for authorities to intervene in an urgent
situation without engaging in further deliberation. Thus sentinel devices
do not operate on their own but are integrated into a broader system of alert-
and-response, one that includes preparedness plans that instruct officials in
how to respond and decision instruments that guide governmental intervention
as the event unfolds. As we will see in the next section, however, such
responses may be subject to criticism from actors who are invested in an
actuarial approach, and who doubt the legitimacy of vigilance as a technocratic
mode. A recent European controversy around vaccination policy – though it
played out in an ‘ethical’ register – is better seen as a critique, from certain
quarters of public health, of the sentinel device as a guide for techno-political
intervention.

The pandemic emergency

When the newly reassorted influenza virus A/H1N1 made its appearance
among humans in the spring of 2009, it seemed to be the pathogen the world
had been waiting for. Early reports indicated that dozens had died from a
mysterious respiratory ailment in Mexico, and hundreds more had been
hospitalized. The incidence of cases from around the United States suggested
rapid transmission of the virus. There was a possibility that this was the
beginning of a catastrophic global pandemic, but its key statistical character-
istics – in particular its case fatality ratio – were not yet known.8
Within weeks, an extensive global public health apparatus had taken hold of
the virus, tracking its extension through reference laboratories, mapping its
genomic sequence, collating data on hospitalization and death rates, working to
distribute anti-viral drugs and develop a vaccine and, not least, communicating
risk (and uncertainty) to the public. While some elements of this apparatus
were decades old – for example the Global Influenza Surveillance Network and
the egg-based technology of vaccine production – others were quite new, such
as internet-based disease reporting systems, molecular surveillance methods
and national pandemic preparedness plans.
Based on the early reports from Mexico, World Health Organization
(WHO) Director-General Margaret Chan declared a ‘public health emergency
of international concern’ (PHEIC) under the revised International Health
 Andrew Lakoff: Real-time biopolitics 47

Regulations (IHR). Here the sentinel device was linked up to an already-

constructed decision instrument designed to authorize technocratic action
under conditions of uncertainty. According to the IHR, the declaration of a
PHEIC points to the onset of a generic biological threat – whether a pandemic
of a novel disease, a bioterrorist attack or an ecological accident. It leads to the
appointment of an Emergency Committee by the WHO Director-General,
which in this case initially recommended a ‘pandemic alert’ level of Phase 4.
Given the controversy that followed, it is important to note that the definition
of ‘pandemic’ from the WHO’s (2009) pandemic preparedness guidance
document referred to ‘sustained community level outbreaks’ in multiple
regions but made no reference to the severity of the virus (WHO, 2009).
Soon after, on 29 April, the Emergency Committee increased the official
pandemic alert level to Phase 5 – which, again following the WHO pandemic
preparedness guidance document, indicated that national health authorities
should move from ‘preparedness’ to ‘response’ activities. Director-General
Chan assured members of the public that WHO was tracking the emerging
pandemic at multiple registers – epidemiological, clinical and virological – and
meanwhile advised national health ministers to ‘immediately activate their
pandemic plans’ (Chan, 2009a). For North American and European govern-
ments, among other things, this meant triggering advanced purchase agree-
ments with drug companies in order to secure millions of doses of flu vaccine
in time for anticipated mass H1N1 immunization campaigns in the coming
fall.9 Thus, in the absence of statistical data on the severity of the virus, the
pandemic alert system provided health officials with guideposts for action. As
the pandemic preparedness document put it: ‘This phased approach is
intended to help countries and other stakeholders to anticipate when certain
situations will require decisions and decide at which point main actions should
be implemented’ (WHO, 2009, p. 26).
Shortly after the virus’ initial appearance, in May 2009, an editorial in the
journal Science co-authored by the president of the Institute of Medicine
described flu experts’ work to track epidemiological patterns in the field and
viral mutations in the laboratory during the very course of the epidemic,
emphasizing the novelty of the technical capacities involved: ‘By conducting
the right science and communicating expert judgment, scientists can enable
policies to be adjusted appropriately as an epidemic scenario unfolds’
(Fineberg & Wilson, 2009, p. 987).10 This capacity to adjust policies for
managing the population’s health to unfolding events in real time can be
contrasted with the actuarial approaches described above, in which future-
oriented policies are justified through the accumulation of historical data on
disease risk.
On 11 June 2009, Director-General Chan announced pandemic alert Phase 6,
or a ‘full global pandemic’. In her statement to the public, Chan emphasized
the organization’s ongoing vigilance as the event unfolded: ‘No previous
pandemic has been detected so early or watched so closely, in real-time, right
at the very beginning’, she said. ‘The world can now reap the benefits of
48 Economy and Society

investments, over the past five years, in pandemic preparedness’ (Chan,

2009b). Such vigilance, then, was based on prior anticipation of the
emergence of a novel and deadly strain of flu. At the same time, the
Director-General warned about the inherent unpredictability of influenza:
‘The virus writes the rules and this one, like all influenza viruses, can change
the rules, without rhyme or reason, at any time’. Thus vigilant watchfulness
would continue to be necessary.
As of early July, influenza experts were still trying to figure out what
H1N1’s ‘rules’ were – especially its rules of transmissibility and virulence.
A critical problem was the lack of quantitative data on the overall incidence
(as opposed to the number of fatalities) of H1N1 in the population. This was
the well-known ‘problem of the denominator’. A team of Harvard-based
epidemiologists made the case for immediate investment in serologic surveys of
populations that would make it possible to calculate the case fatality ratio. As
they wrote: ‘Without good incidence estimates, estimates of severity will
continue to suffer from an uncertain denominator. The effectiveness of control
measures will be difficult to assess without accurate measures of local
incidence’ (Lipsitch et al., 2009, p. 113). Such efforts represented an attempt
to move from vigilance to risk management through the intensive accumula-
tion, sharing and analysis of epidemiological data.
As the pandemic unfolded in its early stages, critical policy decisions on
issues such as school closure and vaccine composition (whether, for example,
scarce supply should be expanded through the use of untested adjuvants) had
to be made in the absence of fully elaborated risk data. ‘In practice’, as the team
of epidemiologists put it, ‘decisions have had to be made before definitive
information was available on the severity, transmissibility, or natural history of
the new H1N1 virus’ (Lipsitch et al., 2009, p. 112). Beginning in the late
summer of 2009, the US government spent $1.6 billion on 229 million doses of
vaccine in what The Washington Post termed the ‘most ambitious immunization
campaign in US history’ (Stein, 2010). Health officials envisioned a possible
shortage of vaccine given anticipated high public demand and long production
time, and implemented a prioritization scheme focused on maintaining
essential services and on protecting ‘vulnerable populations’.11 Nonetheless,
in the early fall in the United States, delays in vaccine production led to
confusion and criticism, but this faded as the anticipated fall wave of H1N1
arrived without a catastrophic number of deaths. Given the response to the
vaccination campaign in Europe (described below), it should be noted that in
their public statements, US Centers for Disease Control (CDC) officials
repeatedly emphasized their uncertainty about the eventual severity of the
disease. Indeed, the assertion of uncertainty about the future course of the
disease was an explicit element of public risk communication strategies.
Further, one might say that in order to sustain demand for its operation, an
apparatus of vigilance requires the ongoing construction of such uncertainty.12
In Europe, when the fall wave arrived, the apparent mildness of the virus
led to widespread scepticism of the legitimacy of state-led vaccination
 Andrew Lakoff: Real-time biopolitics 49

campaigns. The French government had spent an estimated five hundred

million euros on a campaign that in the end immunized only 10 per cent of the
population. Meanwhile, sceptics in the UK and elsewhere protested that the
swine flu pandemic was a ‘hoax’ that had been staged for the benefit of
international health authorities and the global pharmaceutical industry. By the
winter, the governments of France, Germany and the UK all sought to
renegotiate their advanced purchase agreements with vaccine manufacturers and
to unload excess doses on poor countries in the Global South at bargain prices.13
A number of political controversies then erupted over the intensive public
health response to H1N1. Criticisms of government spending on vaccination
were linked to broader debates over the perceived shrinking of the welfare
state. In Le Monde, former French Red Cross president Marc Gentilini
admonished the government for its spending on the campaign, noting that
‘preparing for the worst wasn’t necessarily preparing correctly’ (Chaon, 2010).
A physician and legislator for the governing conservative party decried the
misallocation of public health resources, saying ‘the cost is more than the
deficit of all France’s hospitals and is three times [the amount spent] on cancer
care’ (Daneshkhu & Jack, 2010). The French government in turn defended its
actions on the grounds of precaution: ‘I will always prefer to be too prudent
than not enough’, said President Sarkozy (Whalen & Gauthier-Villars, 2010).14
And Foreign Minister Bernard Kouchner, no stranger to disease emergencies,
declared that he was ‘scandalized by the fact that this is a scandal at all’
(National Public Radio, 2010).
The attention of critics then turned to the warnings from international flu
specialists that had that led to the mass vaccination campaigns. As Gentilini
put it, ‘I don’t blame the health minister, but the medical experts. They
created an apocalyptic scenario. There was pressure from the World Health
Organization, which began waving the red warning flags too early’ (National
Public Radio, 2010). The head of the French Socialist Party demanded a
parliamentary inquiry, calling the vaccination campaign a ‘fiasco’ and arguing
that multinational drug companies were ‘the big winners in this affair’
(Daneshkhu & Jack, 2010). The Chair of the Council of Europe’s Health
Committee, German physician Wolfgang Wodarg, convoked public hearings
on the matter, charging that the WHO pandemic declaration was ‘one of the
greatest medical scandals of the century’ (Macrae, 2010). Influenza vaccination
sceptics cast doubt on the very premise that the flu should be put at the centre
of global public health attention. As Tom Jefferson of the Cochrane Institute
put it, ‘the importance of influenza is completely overestimated. It has to do
with research funds, power, influence and scientific reputations’ (Grolle &
Hackenbroch, 2009).
Witnesses before the Council of Europe’s Health Committee argued that
scarce public health resources had been squandered on a disease that turned
out to be less dangerous than seasonal flu, and that such resources should have
been spent on ‘real’ killers – whether heart disease in wealthy countries or
infant diarrhoea in poor ones. German epidemiologist Ulrich Keil (2010, p. 3)
50 Economy and Society

cited national statistics on disease mortality to criticize the WHO’s emphasis on

managing ‘emerging diseases’ at the expense of the actual ‘great killers’
detected through epidemiology: ‘I like to point out that of the 827,155 deaths
in 2007 in Germany about 359,000 come from cardiovascular diseases, about
217,000 from cancer, 4,968 from traffic accidents, 461 from HIV/AIDS and
zero from SARS or Avian Flu’. Here, coming from a certain segment of public
health experts, we find the public display of numbers to make the case for
rational decision on the basis of risk calculation, rather than based on alarm
about potential (if uncertain) catastrophe. Keil continued: ‘Governments and
public health services are paying only lip service to the prevention of these
great killers and are instead wasting huge amounts of money by investing in
pandemic scenarios whose evidence base is weak’. Of course, from the vantage
of vigilance, there is no possibility that such epidemiological evidence could be
strong, since it is oriented precisely to events that have not yet occurred.
Rather than see the WHO response as a different type of reasoned action –
one concerned with anticipatory intervention in the face of an uncertain
threat – critics denounced a breach of scientific ethics, arguing that hidden
conflicts of interest among members of the Emergency Committee had led to
the WHO’s pandemic declaration. One object of critics’ suspicious attention
was the apparent removal of the measurement of severity from the official
WHO pandemic preparedness guidance document several months before the
appearance of the new strain of H1N1. In June, investigative reporters with the
British Medical Journal revealed paid consulting relationships between leading
WHO influenza experts and vaccine manufacturers: ‘Our investigation has
identified key scientists involved in WHO pandemic planning who had
declarable interests, some of whom are or have been funded by pharmaceutical
firms that stood to gain from the guidance they were drafting’ (Cohen &
Carter, 2010, p. 1274). The same week, the Council of Europe released its
official report, which claimed that the pandemic declaration had led to ‘a
distortion of priorities of public health services across Europe, waste of huge
sums of public money, [and the] provocation of unjustified fears among
Europeans’, and suggesting that WHO deliberations had been tainted by
unstated conflicts of interest between influenza experts and the drug
companies that profited from the vaccine campaign (Council of Europe,
2010, p. 17).
A review committee later charged with inquiring into the WHO response to
H1N1 ‘found no evidence of attempted or actual influence by commercial
interests on advice given to or decisions made by WHO’, and strongly
defended the integrity of its influenza specialists: ‘In the Committee’s view, the
inference by some critics that invisible commercial influences must account for
WHO’s actions ignores the power of the core public health ethos to prevent
disease and save lives’ (WHO, 2011, p. 17). Arguably, a denunciation of
conflict of interest was the most easily available idiom of critique for those who
did not accept the legitimacy of the normative rationality embedded in sentinel
devices.
 Andrew Lakoff: Real-time biopolitics 51

More interesting than the debate over conflict of interest is the question of
how a non-actuarial style of reasoning comes to be built into the devices that
guided WHO decision-making. How, in other words, did sentinel devices
come to prominence in the global management of infectious diseases? Another
way to pose the question is to ask: how did such a weak virus generate such a
strong response? Here we must briefly turn to the recent history of the field of
‘global health security’, which both constitutes the threat of emerging disease
and develops tools for responding to its onset.

Detecting the unanticipated

Perhaps not surprisingly, the critical event in this history is the HIV/AIDS
crisis of the 1980s and 1990s, which disrupted a public health narrative
according to which infectious disease had gradually been conquered through
increasingly stable methods of public health prevention. For a group of mostly
US-based virologists and tropical medicine specialists, AIDS not only upended
this story of progress, it was best understood as a herald of further crises to
come. From this perspective, massive social and ecological transformations had
led to the emergence of novel pathogenic threats, such as Ebola, West Nile
virus and drug-resistant tuberculosis (Cooper, 2006; King, 2002). This was a
pattern, they warned, that would only intensify in an era of increasing human
incursion into the environment, global migration and deterioration of existing
public health infrastructure.
For these infectious disease experts, traditional approaches towards the
prevention of known diseases could not address the expected onslaught of
novel or resurgent pathogens. In an important 1993 collected volume on
emerging viruses, epidemiologist Donald A. Henderson, who had led the
WHO’s small-pox eradication campaign in the 1970s, described the problem as
follows: ‘Human health and survival will be challenged, ad infinitum, by new
and mutant microbes, with unpredictable pathophysiological manifestations.
As a result, we are uncertain as to what we should keep under surveillance or
even what we should look for’ (Henderson, 1993, p. 283).15 A method for
detecting and responding quickly to novelty was needed. Henderson was a
veteran of the CDC’s vaunted Epidemic Intelligence Service (EIS), whose
approach was, as EIS founder Alexander Langmuir (1963, pp. 182–3) put it,
one of ‘continued watchfulness over the distribution and trends of incidence
through systematic consolidation and evaluation of morbidity and mortality
and other relevant data’. In the WHO eradication campaign, Henderson had
used the method of real-time disease surveillance in tracking and containing
the global incidence of small-pox. To address the challenge of emerging
pathogens, he proposed the development of a global network of surveillance
centres and reference laboratories that would extend this approach to as-yet
unknown diseases, providing early warning of disease outbreaks of any kind.
Such vigilant monitoring, linked to active response systems, would make it
52 Economy and Society

possible to contain an outbreak of a highly virulent and transmissible new

disease before it became a global catastrophe.
Over the following decade it became evident to emerging infectious-disease
experts that a major impediment to implementing such a global monitoring
system was the reluctance of national governments to release information about
disease outbreaks, for fear of disrupting trade and tourism. Notorious cases
included widespread and initially unreported outbreaks of cholera in Venezuela
in 1992 and of plague in India in 1994. In 2002, the outbreak of SARS in
China provided these experts with an opportunity to experiment with non-
state-based sources of epidemiological information. As an unknown and
unexpected but potentially catastrophic virus, SARS fits well into the category
of ‘emerging diseases’. Given the Chinese government’s initial failure to report
the outbreak or allow international authorities to investigate, WHO experts
relied on unofficial sources (specifically GPHIN, the Global Public Health
Intelligence Network, which searched digital media for journalistic reports on
outbreaks) to track the disease’s spread (Weir & Mykhalovskiy, 2007).
SARS confirmed the concern among emerging-disease experts about new
pathogenic threats that transcended national boundaries: only a global system
of real-time disease surveillance could provide adequate warning to enable
containment. As WHO official David Heymann (2004) put it, ‘inadequate
surveillance and response capacity in a single country can endanger the public
health security of national populations and in the rest of the world’. Only a global
system of rapidly shared epidemiological data, assembled in real-time, could
provide adequate warning to mitigate such risks. National sovereignty would
have to accede to the demands of ‘global public health security’ (Collier &
Lakoff, 2008). The elements making up this proposed system – a network of
disease surveillance, a method for enforcing national compliance, protocols for
action in the event of emergency and procedures for producing and dissemin-
ating medical counter-measures – had been brought together through a
collective act of imagination: what a catastrophic disease scenario would look
like, and what mechanisms would have to be put in place to avert its occurrence.
Reformers advocated a major revision of the existing IHR as a means to
implement such a system. The existing regulations, adopted in 1851 and
designed to keep goods circulating between trading nations in the event of
epidemics, required reporting on only the three classic nineteenth-century
diseases linked to travel (cholera, plague and yellow fever) and relied on
national health agencies publicly to report outbreaks. Thus they were
ineffective in an era in which new diseases were constantly appearing and
national governments were prone to hide the occurrence of deadly outbreaks.
For the reformers, two revisions to IHR would make it possible rapidly to
detect and respond to the emergence of novel pathogens: first, the invention of
a generic category of disease event, the PHEIC; and second, the official
recognition of non-state sources of information on outbreaks, such as
journalistic reports (Fidler & Gostin, 2006). Given these two changes, it was
hoped, global disease surveillance systems attuned to unprecedented pathogens
 Andrew Lakoff: Real-time biopolitics 53

could serve as a distributed sentinel device, no longer bound to national health

bureaucracies and their official case reports.

The next pandemic

The space of emerging disease, initially carved out by AIDS and then
expanded by SARS, was soon occupied by a new threat: the possibility that a
new strain of H5N1 avian influenza would mutate to become easily
transmissible among humans. Such an event could not be predicted, but –
experts warned – would be catastrophic. As of 2005, when global avian
influenza preparedness efforts intensified, the strain had killed over 50 per cent
of those who had contracted it and was spreading globally among migratory
birds and domesticated poultry. In a 2005 Foreign Affairs article journalist
Laurie Garrett evinced both the dire scenario of an H5N1 pandemic and the
uncertainty surrounding it:

In short, doom may loom. But note the ‘may.’ If the relentlessly evolving virus
becomes capable of human-to-human transmission, develops a power of
contagion typical of human influenzas, and maintains its extraordinary
virulence, humanity could well face a pandemic unlike any ever witnessed. Or
nothing at all could happen. (Garrett, 2005, pp. 3–4)

The prospect of such catastrophe lent urgency to the enactment of pandemic

preparedness measures in North America and Europe, which included the
adoption of the revised IHR and the six-phase pandemic alert system that
would guide decision-makers in the event of an outbreak.16 On the one hand,
H5N1 was a vehicle for a more general form of pandemic preparedness; on the
other hand, it also provided the details of the scenario that would constrain
response when a different pathogen arrived.
When a novel, humanly transmissible strain of influenza appeared in 2009,
plans that had originally been developed to prepare for H5N1 were put into
action. As an official from the European Centre for Disease Prevention and
Control later put it, explaining the intensive global response: ‘We were all
planning for the potential mutation of the avian flu over the next three to
five years into a person-to-person transmittable disease’ (Amies, 2010).17
This was also true of ‘public risk communication’ strategies; in an image
from early in the swine flu outbreak, a US newscaster projected potential
mortality figures for H1N1. These projections, as a caption in the image
revealed, came from 2005 Department of Health and Human Services
scenarios based on H5N1.
It was the use of such scenarios as guides to action in the absence of
statistical data about disease risk that had so exercised the WHO’s critics. As
the Council of Europe’s scathing report put it: ‘It was precisely this lack of
watertight evidence about the influenza phenomenon which led to the fears of
54 Economy and Society

the pandemic being exaggerated and the subsequent disproportionate

response’ (Council of Europe, 2010, p. 8). But from the vantage of WHO
pandemic planners, it is only in retrospect that such an assessment can be
made: from the perspective of vigilance, as soon as a sign of the catastrophic
future is detected, already-existing plans must be put into action.
In response to critics’ accusations of conflict of interest, Director-General
Chan chartered a review of the agency’s response under the aegis of IHR. In
her September 2010 testimony to the Review Committee, she revised her
earlier statement about the benefits of investments in preparedness: ‘The world
was better prepared for a pandemic than at any time in history. But it was
prepared for a different kind of event than what actually occurred’ (Chan,
2011). Chan tersely admitted that dire scenarios based on H5N1 had
structured the agency’s response: ‘Managing the discrepancy between what
was expected and what actually happened was problematic’, she said.
In its final report, the IHR Review Committee absolved the WHO Emergency
Committee of any ethical violations, but emphasized the difficulty WHO had
faced in adjusting to the unexpected. The Committee’s statement was a clear
articulation of the norms that should be built into a sentinel device: ‘Lack of
certainty is an inescapable reality when it comes to influenza. One key implication
is the importance of flexibility to accommodate unexpected and changing
conditions’ (WHO, 2011, p. 10).18 In other words, one must track and respond
to transformations in real time. In response to charges that WHO experts had
intentionally overstated the seriousness of the pandemic, the Review Committee
argued that ‘reasonable criticism can be based only on what was known at the
time and not on what was later learnt’, pointing out that ‘the severity of the
pandemic was uncertain throughout the summer of 2009, well past the time, for
example, when countries would have needed to place orders for vaccine’ (WHO,
2011, p. 17). In the case of a novel pathogen, the virulence of an encroaching
epidemic cannot be determined based on accumulated data about the past. At a
moment of critical decision, one inevitably will suffer from a dearth of numbers.
In the 1830s and 1840s, the actuarial device in public health was invented in
the broader context of an attempt to know and manage the regularly occurring
risks of collective urban life. A century and a half later, sentinel devices
proliferated in response to a different problem, that of the unanticipated but
potentially catastrophic disease event in a globally interconnected world. These
two kinds of security mechanisms, one dating from the early nineteenth
century and the other from the late twentieth, encountered one another around
the question of what kind of event A/H1N1 (2009) was to be: an alarm
precipitously sounded or a bullet barely dodged.
If risk management guided national public health efforts up through the late
twentieth century, the recent appearance of ‘emerging infections’ points to the
limit of its capacity to govern disease. An apparatus of vigilance, constructed at a
global scale, seeks to envision future disease catastrophe and to put tools in place
that can avert its occurrence. Among these tools are sentinel devices that alert
authorities to the onset of a potential event and, just as important, trigger
 Andrew Lakoff: Real-time biopolitics 55

mechanisms that direct policy intervention in the wake of an alert. National

public health officials, once enrolled in this apparatus, cannot evade responsib-
ility for taking precautionary measures, however costly, by citing the lack of data
on disease risk.
The WHO’s pandemic preparedness planners might have responded to the
Council of Europe’s critical report with this line from philosopher Hans Jonas,
writing about the principle of precaution: ‘the prophecy of doom is made to
avert its coming, and it would be the height of injustice to later deride the
“alarmists” because “it did not turn out to be so bad after all” – to have been
wrong may be their merit’ (Jonas, 1985, p. 120). And yet, despite the ubiquity
among emerging disease experts of phrases like ‘it is not a question of if, but
when’, prophecy is not the right term for the field’s characteristic orientation
to the future, since it insistently admits its uncertainty. Rather, the figure of
the sentinel, ever alert but hypersensitive, helps us to understand the particular
form of anticipation at stake in the arena of global health preparedness.

Disclosure statement

No potential conflict of interest was reported by the author.

Notes

1 As he writes at the outset of the third lecture, ‘This year my plan was to bring out
what is specific, particular, or different in the apparatuses of security when we compare
them with the mechanisms of discipline I have tried to identify’ (Foucault, 2007, p. 55).
2 ‘I think the integration of the town within central mechanisms of power, or better,
the inversion that made the town the primary problem, even before the problem of the
territory, is a phenomenon, a reversal, typical of what took place between the
seventeenth and the beginning of the eighteenth century. It was a problem to which
it really was necessary to respond with new mechanisms of power whose form is no
doubt found in what I call mechanisms of security’ (Foucault, 2007, p. 64).
3 Hacking (1990, p. viii) calls this process ‘the avalanche of printed numbers’.
4 Niklas Luhmann (1998, p. 70) describes the relation between present decision,
based on risk calculation, and potential future responsibility: ‘the present can calculate a
future that can always turn out otherwise; so the present can assure itself that it
calculated correctly, even if things turn out differently’.
5 See ‘Farr’s biometer: The life table and its applications in medicine and economics’,
in Eyler (1979).
6 See ‘Inequality before death: Paris’, in Coleman (1982). See also Rabinow (1989).
7 Important contributions to the growing literature on the question of the limits of
actuarial rationality in dealing with catastrophic events include Bougen (2003), Ericson
and Doyle (2004) and Collier (2008).
8 The first US cases of A/H1N1 were detected in April 2009 by a naval disease
surveillance project supported by the US Armed Forces Health Surveillance Center’s
Global Emerging Infections Surveillance and Response System (AFHSC-GEIS), a
56 Economy and Society

sentinel device for detecting the emergence of novel pathogens. A report from the
AFHSC notes: ‘By supporting global surveillance and supporting local response efforts,
DoD serves as a sentinel for local epidemics and can assist in limiting disease
transmission’ (Burke, 2011, p. 2).
9 For a discussion of the controversy that arose around inequitable global access to the
H1N1 vaccine, see Fidler (2010).
10 The co-author of this paper, Harvey Fineberg, had also co-authored a book on the
1976 swine flu ‘fiasco’ that diagnosed US health officials’ failure to respond flexibly to
an uncertain event (Lakoff, 2008). In 2010, he was named the chair of the committee
charged with investigating the WHO’s (2009) response to H1N1 under the aegis of
the IHR.
11 The prioritization scheme was the product of long-term preparedness planning,
oriented towards the goal of protecting the functioning of ‘critical infrastructures’
during a health emergency.
12 Based on fieldwork at the US CDC, anthropologist Theresa MacPhail (2010)
argues that ‘strategic uncertainty’ was used to maintain scientific and public health
authority throughout the H1N1 episode.
13 Of course, had the strain proven more virulent, a very different scandal might have
arisen around the question of unequal access to medical counter-measures in the event
of pandemic emergency.
14 Frédéric Keck suggests that the French government was constrained in its
response to H1N1 by a framework of ‘precaution’ – as opposed to preparedness, which
might have implied a more flexible and less immediately intensive response (Mongin &
Padis, 2011).
15 The volume came out of a 1989 meeting co-organized by Stephen Morse and
Nobel prize-winning biologist Joshua Lederberg.
16 It should be noted that the alert system was specific to pandemic influenza, and did
not apply to other IHR events. And while all IHR signatories were bound to respond to
a WHO PHEIC, not all member states had adopted the pandemic alert system.
17 The IHR Review Committee agreed with this assessment: ‘The response to the
emergence of pandemic influenza A (H1N1) was the result of a decade of pandemic
planning, largely centred on the threat of an influenza A (H5N1) pandemic’ (WHO,
2011, p. 10).
18 Intriguingly, this was the same conclusion that the Review Committee chair,
Harvey Fineberg, had reached in his co-authored book evaluating the much-criticized
US CDC response to swine flu in 1976 (Neustadt & Fineberg, 1983).

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Andrew Lakoff is an Associate Professor of Sociology at the University of

Southern California. He is the author of Pharmaceutical reason: Knowledge and
value in global psychiatry (Cambridge, 2006), and co-editor, with Stephen J.
Collier, of Biosecurity interventions: Global health and security in question
(Columbia, 2008).