Methodology

The data presented in this article were collected as part of a larger study undertaken for [FB]’s doctorate [36]. The overall approach adopted in the research project of which that reported in this paper is a part is that of symbiotic empirical ethics, which aims to integrate empirical data with normative enquiry [37]. Within that context, this article focuses in particular on a key theme from the qualitative analysis.

Method

Qualitative data collection was undertaken between 11^th June 2021–11^th April 2022, by means of 38 semi-structured interviews. Interviews were conducted with public health or policy professionals who currently or previously identify as being involved in global health security – broadly understood – and/or working in related areas in the context of acute infectious disease outbreaks (including from public health, government, NGOs, think tanks, and academia). The sampling strategy used a mix of purposive and snowball sampling. The purposive sampling strategy was aimed at identifying and gathering data from a varied range of perspectives, and was informed by a stakeholder mapping exercise to increase diversity in participants by geographical location, sector, and professional background. The study was designed prior to the start of the COVID-19 pandemic, but the interviews were undertaken during it.

Interviewees were contacted primarily by email, with an initial invitation including a participant information sheet, and a reminder email if no response. Of the 63 potential interviewees invited to participate, 38 (60%) chose to participate in the study. Interviews were conducted remotely by FB from two different time zones (Greenwich Mean Time/ and Pacific Standard Time). A semi-structured topic guide was developed with questions on interviewee’s role, definitions of global health security, ethical concerns within global health security and COVID-19. The topic guide was iteratively adapted as the interviews progressed, to reflect how well questions worked and to include ideas brought up unprompted by interviewees that seemed pertinent to research aims.

The decision to cease data collection relied on the theoretical idea of data saturation. In practical terms this meant that a decision was made to conclude data collection at a point when it was judged that the data collected were comprehensive and in depth, and when there appeared to be no new key insights or themes emerging, rather than seeking all data collected to be repetitious [38,39]. Some of the key ideas seemed to reach saturation at an earlier point, such as the idea of boundary setting around the definition of global health security. However, we were keen to ensure this was due to the fact that all the key themes in these areas had been explored, rather than that some kinds of people had been excluded from the study. Therefore further efforts were made to purposively recruit participants with backgrounds that were underrepresented in the sample, including those working in the Global South [38,39]. However, as the sample was expanded, there were few new perspectives gained (see Limitations section). Data collection therefore continued until April 2022 when it was judged that this further recruitment was producing any further new ideas.

The majority of interviewees resided in Europe (47%), North America (24%) or Africa (18%), and were senior career professionals (63%) with a background in health (55%) or public health and epidemiology (47%) (Table 1). A common career path for participants included multiple years of postgraduate training or education to work in healthcare before moving onto careers in areas of public health, global health security, or humanitarian work.

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Table 1. Interviewee characteristics.

https://doi.org/10.1371/journal.pone.0348139.t001

In the results presented, pseudonyms are used for interviewees, alongside contextual information on working location and current role.

Data analysis

Audio recordings were transcribed by a professional transcriptionist and uploaded to NVivo V1.6 [40]. The interview transcripts were analysed by FB using thematic analysis, a six stage method for analysing qualitative data in order to identify key themes that explained that data [41,42].

After data familiarization, initial interviews were coded in great detail, with line-to-line coding, to generate a large number of initial codes (50+). These initial codes were then grouped into broader codes that were related through meaning or topic. After the first half of the data was coded, we started the process of collating codes into related groups, to build themes. This involved an iterative process of moving between codes to identify commonalities. These initial themes were discussed and reviewed once all the dataset was coded, and at this point some of the latent themes, that categorise the underlying ideas or assumptions in the data were developed.

To increase rigor, FB, PK, and MP all read and discussed the initial transcripts coded by FB, followed by regular monthly discussion of coding extracts and themes. This allowed for themes and codes to be challenged and analysed at an early stage. In a second coding group of four doctoral students, a further transcript extract was coded by all four members with results compared to increase inter-coder reliability. Reflective notes were written by FB before, during, and after conducting the qualitative study to constitute a form of self-appraisal in research [43]. FB discussed key methodological and analytical decisions with PK and MP.

Ethics approval and consent

Approval to conduct this study was received from the University of Oxford Medical Sciences Interdivisional Research Ethics Committee (reference R62941/RE001).

Care was taken to ensure interviewees provided informed consent to participate in the study. Interviewees received the information sheet and consent form before the interview, then the study and its risks were discussed at the start of each interview. All interviewees completed a written consent form, except for two: one confirmed consent via email, and the other provided oral consent in line with University of Oxford guidance on oral consent.

Boundary setting

A key strategy adopted by interviewees when asked to define global health security was to specify or list what issues and diseases were inside or outside the concept, that is, to set boundaries using examples. This was both something explored explicitly in the interview topic guide (for example, prompts on: “is malaria a global health security problem? Why?/ Why not?”), but was also something interviewees spontaneously discussed.

Moral concerns about global health security

As well as setting boundaries to what is included or excluded in global health security based on different categories of pathogen interviewees’ expressed moral concerns about the enterprise and language of what global health security is. These concerns, which were expressed by many interviewees, are relevant to the meaning of global health security because they are concerns about the enterprise and language of what global health security is. By interviewees expressing these concerns, insights are gained about the moral meaning and standards global health security should have.

A key moral concern was that the security framing led to an “us and them mentality” (Alvi, North European, public health). The concern expressed by interviewees was that global health security framing can be ethically problematic because it positions the Global North as the beneficiaries of measures to strengthen health security, while casting the Global South as the supposed source of infectious disease outbreaks. This framing, thus, unjustly prioritises the health of populations in the Global North rather than being truly global. This framing is seen as a wider problem arising out of differences in the value attributed to lives in the Global North versus the Global South, as exemplified by Jo:

I think there is a darker side to it which is, ‘We care about my health, and I don’t care about your health, and this is about security of my country of me.’ And I think unfortunately that is often how it’s portrayed in, in non-rich world countries that the global health security agenda is actually about protecting people in rich countries. (Jo, North European, NGO leadership)

Interviewees were also concerned that the issues that global health security represents should be important in and of themselves and should not need the security rhetoric to make them important. Robin objects to the need for security as a motivator for decision-makers suggesting “it would be a better environment if these issues were taken seriously because they are, they are important, not just because they are security threats.” (Robin, North European, international law).

A key question when looking at the question of moral concerns in global health security, is whether it is the activities in global health security or the framing and the language, or both, that interviewees were objecting to. Some interviewees did find it to be the terminology, rather than the connection between security and health that they found troubling. One interviewee put this very strongly:

I mean I, I think the, the, the words are flawed and I, I would not use them...And you can’t ignore what words, might mean to us, what they may mean to somebody else either in the emotion of it or even the translation of it, and words really do matter…It’s why I don’t like the phrase, I wouldn’t use it myself, I think it has negative connotations and it’s very divisive. (Bo, North European, infectious disease)

Thus, for a sub-set of interviewees, even though they acknowledged the link between security and health, the use of the terminology of global health security had such negative connotations as to require that it be rejected. However, in contrast, six interviewees all said global health security was a “useful” term because it acknowledged the link between global health and security, and helped bring a wider audience into global health – a perspective that is also seen in the global health security literature [see for example Heymann in 49].

Four moral models of global health security

In the first part of the results, we have illustrated ways in which global health security can be understood through different boundaries made in relation to pathogen and aetiology of disease, as well as the moral concerns about the enterprise. This section integrates these perspectives to demonstrate that views on global health security can be divided into four different models (Fig 1). These models are grounded in the inductive coding of the interview data, and lead from and build on the earlier analysis on pathogen/disease based boundaries and moral concerns.

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Fig 1. Four moral models of global health security.

https://doi.org/10.1371/journal.pone.0348139.g001

These four models, the threat, collective, reframing and humanitarian models, reflect different ways of thinking about global health security. Three of the models are denoted as ‘insider models’ in which the concept of global health security is to some extent accepted, even if this acceptance is contingent on redefining what the term means (Fig 1). One model, the humanitarian model, is reflective of an ‘outsider’ position in which the concept of global health security may be rejected or unknown. Nevertheless it is in included as one of the four models because it is key to understanding the range of perspectives on global health security.

However, it is important to note that these models should not be taken to imply that the view of individual interviewees sit neatly within a single way of thinking about global health security – interviewees often expressed views that fitted into more than one model. These models should be seen, rather, as a typology of perspectives on global health security that interact through the interpretations and practices of individual professionals and groups. For example, a professional who subscribes to multiple models may encounter situations where tensions between these perspectives must be negotiated. This is a dynamic that similarly applies to groups comprising members who adhere to different models.

In a field characterised by difference and disagreement, the value of these models is that they help illustrate and understand the bases of those disagreements. By doing so, these models provide valuable insights that can help global health security professionals understand differing viewpoints and so manage value conflicts more effectively.

Which model should be used?

An obvious question coming out of the analysis is that if there are four different moral models of global health security, which model should be used? This question in itself presumes the desirability of one widely-agreed understanding of global health security. Whilst this is not necessarily possible, nor desirable, to demarcate global health security so precisely in practice, it is also prudent to consider what are the benefits and risks of expanding global health security beyond the threat model, which is the narrower conception of global health security.

The key ethical argument, that is implied in both the literature [12,26,30–32,50] and the analysis, is that expanding understandings of global health security would solve some of the moral problems inherent in it. The argument here would go that, because moral concerns with the current form of global health security include that it benefits the Global North at the expense of the Global South, expanding it to include more priority diseases of the Global South, as per the reframing model, would make it morally better.

However, this analysis shows why the argument can be problematic. There are interviewees from the Global South who do, to varying extents, adhere to the threat model because of concern with these large-scale biological events. It is also important not to characterise threat model perspectives as reflecting a failure to consider the interests of the Global South, but as a much more nuanced perspective with ethical priorities about preventing widespread pandemics and severe events with global repercussions.

Even if taken at face value, the argument assumes that the most important moral problem is that global health security does not include the concerns of the Global South. If there were other moral concerns, expanding global health security from a threat model to a wider reframing model would not solve these concerns, but simply mean the concerns were applicable to a wider range of areas. For example, if it was agreed that malaria was a global health security threat, an implication might be to focus on stopping the spread of mosquitoes rather than protecting people in existing areas with bed nets. Here, the moral problem would be about whether it is more important to focus on present persons suffering or future persons that might be affected (as is important in the threat model). This example shows that expanding global health security to further areas does not necessary mean that all moral tensions between the different models are solved.

A similar argument can be made for expanding global health security to non-communicable diseases, as found in the collective model. If global health security is problematic since infectious diseases cannot be addressed in isolation from the health systems these are managed in, or from the non-communicable diseases that affect a population’s resilience to infectious disease outbreaks, global health security should be expanded to include these areas [12,29–34,51]. Although this argument is primarily an empirical argument about whether it is effective to address infectious diseases without a wider systems approach, it may also have ethical connotations that it is not fair to try and manage or fund infectious diseases outbreaks in isolation to other components of health [46]. This is as it may prioritise the security aims of stopping diseases spreading at the expense of persons with ill health, who do not divide ill health by different aetiology of disease, but by those diseases that affect them whether this is COVID-19 or diabetes.

The obvious implication to expanding the model in these ways is that global health security essentially becomes equivalent in concept to global health. As already discussed in the introduction, this could have benefits if it brings global health to the attention of persons that otherwise would not be involved [9,19–21]. It also risks that securitising wider areas may not be convincing to policymakers, risking leading to the risk of oversecuritisation and ‘global health security fatigue’ [35,52]. However, the question about how ethically special an emergency is, and how this affects motivation to act are already addressed in the wider bioethics literature [53]. The unintended negative outcome here would be if attempts to widen the definition lead to weakening the credibility of advocates working on combatting epidemics and pandemics.

It would be premature to conclude from this analysis whether the scope of global health security should be expanded or not. However, it indicates that although calls for expanding the boundaries of global health security may be driven by moral concerns, care should be taken in considering whether global health security is the right solution to solving these moral concerns. This is because it is not clear that expanding the boundaries of global health security solves the key moral concern that global health security benefits the Global North at the expense of the Global South, or secondly, that the risks of expanding it from weakening the framing have been sufficiently considered. However, this does not exclude that there may be empirical reasons to expand, the strongest of which might be to do with the artificial divide between global health and global health security. However, this expansion would then need to be established using research methods beyond the scope of this ethical analysis.

It is also important to consider how political power and stability influence the choice of an appropriate model. The fact that interviewees may favour different models at different times does not necessarily mean they are able to advance the moral ideals embedded in those models, since such decisions are often driven by their organisation or nation. Moreover, the suitability of a model may depend on the context: for instance, the humanitarian model is often the most appropriate during a crisis, as it may be neither feasible nor desirable to promote the collective or reframing models in situations of severe political instability, whether caused by infectious disease, natural disaster, or conflict and violence.

What this analysis adds

This analysis adds empirical evidence and nuance from those working in global health security, and considers implications of expanding the definition which have not previously been seen in the literature. Understandings of global health security among practitioners are multifaceted and complex and pull in different directions. For example, in some aspects their views might tend to pull in the direction of expanded accounts of global health security. In others they will tend to pull towards a narrower account. These tensions are something that those working in global health security have to struggle with as part of their roles. Consequently, these models offer important insights that may be useful to global health security professionals in understanding conflicting perspectives and navigating disagreements.

How global health security is defined carries significant practical consequences, shaping how normative frameworks and practitioner perspectives are translated into institutional arrangements, workforce development strategies, training programs, and broader system-strengthening efforts. For example, proponents of a threat-based model may adopt a relatively narrow conception of capacity building, prioritizing fields such as microbiology and epidemiology to enhance international preparedness, while giving less attention to systems-based approaches to regional health improvement. Such broader approaches might include investments in primary care infrastructure, governance mechanisms, or the accreditation of medical education [54,55]. These differences illustrate that ethical reasoning in global health cannot be confined to disciplinary silos; rather, they highlight the importance of an explicitly interdisciplinary perspective. Practitioners and policymakers in global health security should therefore reflect critically on how funds are prioritized, what is recognized as capacity building, how educational programs are structured, and who funds, participates in, and leads these initiatives.

The international relations literature criticises global health security as driven by self-interest and focused on the containment of diseases for the protection of Western countries [3,7,9]. This article provides a novel perspective by moving beyond these critiques to understand the enterprise as reflecting four distinct moral perspectives. Rather than being mischaracterised as a nationalist approach to global health security—one that asserts greater obligations to fellow nationals over non-citizens and emphasizes national self-interest [56] — we have shown through our analysis that the threat model is more accurately understood as a consequentialist approach, focused on minimizing mortality during epidemics and pandemics. The collective, re-framing, and humanitarian models—and to some extent the threat model—to some extent align with cosmopolitan perspectives on social justice, which place limited moral weight on national borders and view all individuals as having equal claims to aid. [57] This alignment stems from the fact that, although each model emphasizes different values, none rely on the importance of borders. The collective model focuses on cross-border cooperation to uphold individual health rights. The re-framing model advocates redistributing resources to support the most vulnerable. Both the humanitarian and threat models, while consequentialist in nature, prioritize alleviating present suffering and preventing large-scale outbreaks respectively, regardless of where they occur.

This highlights that individuals’ commitments to different models may reflect or be shaped by their broader ethical frameworks, including consequentialist and cosmopolitan perspectives. However, global health discourse is often framed in binary terms, such as casting global health security as the nationalist cousin of a more cosmopolitan vision of global health. These framings fail to capture the moral complexity and real-world dynamics of the field. More nuanced moral understandings move the debate beyond the simplistic binary by showing how diverse ethical perspectives can inform refined positions, shape policy discussions, and support the inclusion of a wider range of viewpoints.