- Unprepared: Global Health in a Time of Emergency by Andrew Lakoff
Among public health experts, it has become commonplace not to ask if a flu pandemic will strike, but rather when this will occur. Andrew Lakoff's book, Unprepared: Global Health in a Time of Emergency, outlines how this type of pandemic awareness—as both a rationale and a governmental tool—is by no means self-evident and is rooted in Cold War defense mobilization and planning. Today, while infectious diseases such as AIDS, malaria, and tuberculosis remain some of the world's leading causes of death, especially in the Global South, few have gained as tremendous visibility in terms of biomedical, political, technological, and media attention as pandemic influenza. With its potentially high mortality rate and great mutagenic potential, pandemic influenza ranks among the most prominent infectious diseases. It is in this context that pandemic preparedness, in very general terms, might be understood as a modality of future-oriented emergency and resilience planning. As such, it has been implemented in countless plans and guidelines on a local, regional, and national scale. These plans and guidelines share a common underlying framework of a scenario depicted as event-like, sudden, disruptive to business continuity, and catastrophic. In this context, Lakoff's genealogical account portrays preparedness not as a destination to be reached, but rather as a continuous attempt to manage and survey potential disease threats transcending geographical, political, and disciplinary boundaries. As such, the book represents a welcome addition to recent accounts of global health security, infectious disease management, and disease prevention history. [End Page 993]
Unprepared is structured in roughly six parts, and does not focus exclusively on pandemic influenza, but rather uses the US preparedness rationale as a framework to critically scrutinize strategic logic underlying current global health (security) approaches. The essay-like chapters cover a time span ranging from mid-1950s nuclear attack preparedness to the 2014 African Ebola outbreak, and a number of heterogeneous infectious diseases such as influenza, Zika virus, anthrax, or hemorrhagic fever—commonly classified as (re-)emerging diseases. Overall, Lakoff's aim was not to develop a comprehensive theory of security or to determine if and how international health officials might have failed in the management of past outbreaks. Instead, he uses a conceptual-historical analysis of officially publicized documents (expert speech acts, so to speak) to analyze the emergence of the global health security apparatus since the early 1990s. Occasionally, argumentative links between the chapters could have been stronger, as they sometimes resembled autonomous papers in scholarly journals. In his introduction, Lakoff provides links between his often heterogeneous and detailed material (ranging from Hurricane Katrina and the Cold War to humanitarian biomedicine, surveillance networks, and Ebola). In particular, he asks what exactly constitutes an emergency—what do emerging diseases have in common? Why does emergency management matter—and to whom?
These are valid questions, and the answers presented by Lakoff are indeed compelling. In his analysis, he portrays an increasingly interconnected world often met with both the political and biomedical assumption that infectious agents do not recognize borders, and that interconnectedness makes it necessary to develop rapid responses designed to provide security against emerging infections. When viewed from a global health perspective, some truism exists behind this assumption; however, many recent works in the social sciences have been particularly productive in highlighting the limits of this perspective, namely that borders are being very much recognized by politics, trade, and the pharmaceutical industry, and that current emergency management approaches—assumed to be global in nature—face a number of political and epistemological challenges. Lakoff's book fits well into this line of argumentation. In a thoughtfully constructed narrative, he demonstrates how emerging pathogens are transformed into security problems, and how these are embedded in assemblages of particular institutional arrangements, political positions, and [End Page 994] forms of professional expertise, rather than evoking a unified technical or political response.
The historical emergence of preparedness (covered extensively in Chapters 1 and 2) is closely linked to the early years of the Cold War, when traditional...