Emerging from the racist and separationist histories of colonial, tropical and missionary medicine, and in response to the limitations of international health — which focuses on the (poor) health of people and places “elsewhere” — the field of global health aims to achieve “equity in health for all people worldwide”.

While defining global health remains messy, we must act upon the central ambition of a collective, global response that focuses on attaining equity in health for all. This is about more than the right to health (which is of course key); it is about recognising basic population health principles whereby promoting and ensuring the good health of every individual benefits us all (conversely, leaving anyone or any population group behind is detrimental to the health of us all).

A true global health response requires the ever-elusive political will needed to address the multiple structural determinants of poor health, including promoting the health and wellbeing of people over profit.

While the aspirations of many of us for a fairer, healthier and more just world feel increasingly out of reach, the Covid-19 pandemic threw down a gauntlet. A global health approach is, by definition, necessary to successfully manage a global health crisis. But, as we have seen time and time again with various public health emergencies (Ebola, Zika, H1N1), necessity is not enough. And it is no different in this context. Rather, Covid-19 has amplified existing and ever-increasingly separatist, nationalistic and xenophobic politics globally.

Fears of the “contagious” migrant body overshadow sensible approaches to the management of Covid-19 in the context of a globalised and mobile world. Not only has vaccine nationalism brought the inequities inherent in global biopolitics — and the power of big pharma — to the fore, it has the potential to be translated at the microlevel, with nation-states holding the power to exclude the “undeserving”, “burdensome” migrant from their vaccination programmes. Vaccine nationalism will not only have results on individual and public health, but it will also amplify other forms of discrimination, including in access to vaccination certificates that will likely become a condition for movement across international borders.

Public health has, historically, involved the management of disease outbreaks, and many public health interventions were designed to prevent and/or restrict the movement of people to stop the spread of disease. While such practices are necessary in various forms and different times for communicable disease control, current moral panics circulating globally — and within South Africa — relating to population movements are increasingly used to support and reinforce global health security agendas, resulting in the use of health as an additional mode for securing national borders.

The prevailing fear and threat of the diseased, foreign body as an unknown outsider whose movements should be restricted in order to exercise sovereignty and “protect” a native population is not new. But these public anxieties about “the contamination of space itself by mobile bodies” have, over time, led to multiple actions to prevent or restrict population movements, with international security and sovereignty debates being inappropriately influenced. 

Such approaches echo the ambitions of colonial and tropical medicine which worked to protect the (healthy) coloniser from the (unhealthy) colonised, and falling back on the reductive notion of “international health” which pits the health of “others, elsewhere” against “ours, here”. Such thinking has influenced the restrictions placed by states on people attempting to move from (other, unhealthy) lower-income contexts to (our, healthy) higher-income contexts.

Restricting movement into South Africa from neighbouring countries under the guise of Covid-19 disease control measures risks health for all, fuels xenophobic and anti-foreigner attitudes and fulfils the (unfounded) idea of a dangerous “other” travelling in order to contaminate an innocent “citizen”.  

As Felicia Chang et al write, “Just as open borders are not synonymous with disorderly migration, securitised borders are not synonymous with orderly migration. Walls and hard border controls on movement of people lead to friction between neighbouring states. The harder the borders for the movement of persons, moreover, the greater the risk of injury and death at those places where people may try to pass notwithstanding the heavy controls.”

But there is no question: an effective response to Covid-19 is an equitable one. This isn’t (only) about the right to good health for all; it’s basic public health programming. Failure to ensure access to preventative and treatment interventions — including vaccines — for all, everywhere, undermines any single nation’s sovereign response to Covid-19.

This co-opting of health concerns to justify the securitisation of borders and sovereignty began to emerge at the end of the Cold War, when a renewed approach to what is now framed as Global Health Security (GHS) was initiated. Sara Davies and colleagues describe GHS as a framework for “identifying the threat posed by pathogens in a globalised world… as a way of promoting the need for a collective global response”.

Premised, once again, on the recognition that infectious diseases — such as Covid-19 — know no international border, GHS offers an approach for moving beyond nationalism, sovereignty and the reductive notion of “international health” to take necessary, coordinated action to control an unanticipated pandemic. But in an increasingly nationalistic world, GHS can be co-opted to support ever-more restrictive approaches to the management of movement across a nation’s borders. 

The World Health Organisation (WHO) cautions against this: “While some countries may still opt for extreme protectionism, importation of diseases is always difficult to prevent. The cross-border impact of infectious diseases is better addressed through multilateral efforts”; a collective, global health response is essential.

In an attempt to guide global health security actions, the WHO developed the International Health Regulations, which aim “to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade”.

However, concerns have been raised relating to the dangers of blurring global public health with the global health security agenda. Currently, “there is no consensus on the role and limitations of foreign policy in public health and health security”.

This global health security agenda has, at times, been co-opted by nation-states to strengthen/justify national securitisation agendas, raising concerns about how Covid-19 could provide (further) opportunities for the (mis)application of the important global health security agenda to support and justify an increasingly securitised world. How to respond to this is of concern, particularly in the SADC region, where population mobility and communicable diseases are prevalent, the non-communicable disease burden is increasing and maternal health indicators are poor.

But there is no question: an effective response to Covid-19 is an equitable one. This isn’t (only) about the right to good health for all; it’s basic public health programming. Failure to ensure access to preventative and treatment interventions — including vaccines — for all, everywhere, undermines any single nation’s sovereign response to Covid-19.

As countries begin to roll out Covid-19 vaccination programmes, principles of global health must be at the fore: equity in access will lead to equity in health for all. But how this plays out in a globalised world remains to be seen. Vaccine nationalism is not only about addressing inequities in access to the vaccine globally, it is also about the ways that nation states roll out their Covid-19 vaccination plans. While common public health sense – the central tenet of any successful vaccination strategy – is clear that everyone must be included, will this be the case?

Beyond impacts on individual health and undermining the success of a national vaccination programme, excluding non-citizens promotes the global endeavour to further securitise borders. Given that vaccination certificates are likely to become a requirement for safe and regular international travel, vaccine nationalism may further harm non-citizens by pushing them into unsafe and irregular border crossings. 

Ultimately, vaccine nationalism is more than “just” about inequity in health; it offers opportunities for states to further restrict and manage movement across borders.

How vaccine nationalism will finally play out in South Africa remains to be seen. Beyond the immediate concerns associated with vaccine nationalism — accessing vaccinations in the first place — we must caution against language referring to “citizens” and “South Africans” when developing vaccination strategies.

We must ensure that we refer to all in South Africa when advocating, developing and implementing our vaccine roll-out strategy. Ultimately, there is no place for hypocrisy. We cannot call out the international community on issues of Covid-19 vaccine nationalism if South Africa does not plan for an inclusive national response. DM

Jo Vearey is director and associate professor at the African Centre for Migration & Society, University of the Witwatersrand.