Unprepared: Global Health in a Time of Emergency by Andrew Lakoff (review)

This book joins the recent literature that examines future intervention technologies and identifies a new modality of securing against “future threats” that goes beyond Foucauldian biopolitical security apparatuses. Preparedness within this framework involves multiple techniques emerging in response to the problem of potential uncertainty.¹

One of the first works to present this approach was Andrew Lakoff and Stephen Collier’s edited volume on Biosecurity Interventions.² In their introduction, the editors argued that preparedness combines elements of national security and population security and is directed toward reducing potential damage rather than preventing specific threats. Subsequent studies have also identified related governmental forms, variously termed “preparedness,”³ “anticipation,”⁴ “precaution,”⁵ “preemption,”⁶ “prudence,”⁷ “the politics of possibilities,”⁸ and “resilience.”⁹

The present book shows how a global health security assemblage consisting of diverse elements, experts, and technologies has established “preparedness” as its central governmental modality. It traces both the roots of preparedness from the end of the Cold War to the present and the emergence of this assemblage, analyzing how relevant authorities—public health officials, national security experts, and life scientists—conceptualize and act on an encroaching future of disease emergence. Significantly, the book focuses not only on the changing mode of governing—the emergence of preparedness—but also on the diverse governmental technologies applied within this approach. If the problem has shifted from knowledge-dependent possibilities (accidents, risks), manageable by means of risk technology, to potential threats, what types of intervention technologies become possible?

The book seeks neither to provide a manifesto for the importance of preparedness nor to criticize its failures. Instead, drawing on the perspective of historical ontology, it tracks the emergence of an unstable consolidation of global health security, posing the question: “How did the norm of preparedness come to structure expert thought and action concerning the future of infectious disease?” (p. 12).

Each chapter draws on a different case study to explore how uncertain global health threats can be addressed and made into an object of present intervention, according to different and sometimes competitive rationalities, such as probability, and imaginative enactment, risk assessment, and preparedness. Chapter 1 presents the case of Hurricane Katrina (2005), focusing on how “contemporary authorities seek to manage potential future dangers . . . whose probability cannot be statistically calculated and whose potential consequences outstrip the capacities of existing prevention and mitigation measures (p. 8).”

It distinguishes between two forms of thinking about and intervening on the dangerous future and its potential threats: as a regularly occurring event that can be calculated via probabilities (based on known historical patterns) and managed through risk distribution, or as an unprecedented, potentially catastrophic event whose consequences are to be managed through methods of imaginative enactment (enabling planners to mitigate vulnerabilities).

Chapter 2 discusses the 1976 swine flu outbreak and the 2005 avian influenza threat in the United States, examining how techniques of emergency management migrated to and were implemented within U.S. public health. This “involved the composition of a new object of knowledge and intervention for public health: no longer, or not only, the population but also the infrastructure that underpins response to health emergencies” (p. 9). Chapter 3 discusses the controversy surrounding Indonesia’s refusal to provide the WHO with samples of a new strain of the H5N1 influenza virus. It examines how, from the early 2000s, public health preparedness was extended as a global strategy in relation to the threat of emerging disease, focusing on the development of the 2005 revised International Health Regulations that form part of the WHO’s strategy of “global public health security.” Here, an analytic distinction is made between two regimes for governing global health problems: global health security and humanitarian biomedicine.

Chapter 4 examines the controversy over the WHO’s decision to declare a Public Health Emergency of International Concern over the 2009 swine flu (A\ H1N1) outbreak. It shows how decision instruments for guiding emergency interventions at the early stages...