Back Home, Safe and Sound: The Public and Private Production of Insecurity

Back Home, Safe and Sound: The Publicand Private Production of Insecurity1

Scott Watson

University of Victoria

Challenging the representations of the securitization of migration anddisease as a productive broadening of security studies or as a troublingshift associated with recent developments in international politics, thisarticle explores how the regulation of human movement and contagiousdisease functions to reproduce the international ⁄ domestic foundation ofthe nation-state system and to support the moral basis of exclusion fromindividual states. Drawing on the practices of border and health regula-tion in Canada, and specifically through the technology of insurance, thearticle explores how health and immigration bureaucracies and privateinsurance corporations reproduce the international realm as anarchic,disordered, and dangerous through the representation of certain regionsand peoples as unhealthy, irrational, and dangerous.

The production of insecurity is a preeminent, though contested, area of concernin security studies. A central area of contestation concerns the relative impor-tance of the anarchic international structure and domestic identity construction.In the structural-realist tradition, insecurity is an intrinsic feature of life in ananarchic international system in which all states engage in self-help behavior toensure survival (Waltz 1979:103). Insecurity is produced through the securitydilemma—wherein insecurity stems from a fear of being attacked and throughefforts to enhance one’s security (Herz 1950:157). Conversely, in some construc-tivist scholarship, insecurity is less a product of international structure than ofcertain types of identity configurations. Because ‘‘anarchy is what states make ofit’’ (Wendt 1992), the international system of states is not inherently insecure;and more peaceful anarchic structures are made possible through changesin collective identity and interests (for example, see Adler and Barnett 1998;Cronin 1999; Abizadeh 2005; for a good overview see Rumelili 2008). In thisliberal-constructivist view, certain types of relationships lead to insecurity andconflict, while others are more conducive to peace and security. Treatinginsecurity as a product of state relationships privileges a narrow understandingof security as equivalent to the potential use of violence between states. Further-more, it ignores how the society of states relies on the insecurity withinanarchy—even in Wendt’s ‘‘Kantian anarchy’’—to legitimate, sustain, andprotect differentiated states and the state system. Critical-constructivist scholars(for example, Campbell 1992; Huysmans 1995; Weldes 1999; Connolly 2002)challenge this narrow understanding of insecurity and identity by showing howthe maintenance of boundaries and identity requisite in a system made up of

1Research for this paper was conducted as part of a larger project examining the construction of insecurity inCanada, and was funded through SSHRC. I am grateful to SSHRC for their support. I would also like to thank theanonymous reviewers and the editors for their insightful and constructive comments.

doi: 10.1111/j.1749-5687.2011.00127.x� 2011 International Studies Association

International Political Sociology (2011) 5, 160–177

distinct nation-states necessarily produces insecurity. For example, Weldes, Laffey,Gusterson, and Duvall explain that ‘‘insecurity is not external to the object towhich it presents a threat, but is implicated in and an effect of the process ofestablishing and reestablishing the object’s identity’’ (1999:11). Consequently,insecurity is not a result of an anarchic system, nor of antagonistic identity forma-tions, but of a system comprised of and created by differentiated nation-states.

While the prioritization of identity in the production of insecurity marks animportant shift, this has come at the expense of understanding how anarchyfunctions in and through the production of identity and insecurity. The divisionof modern political life into differentiated nation-states is achieved through theconstruction of an insecure anarchic international realm and a safe domesticrealm. Understanding the production of insecurity requires analysis of both theproduction of the international ⁄ domestic binary that renders differentiatednation-states both possible and necessary, as well as particularistic identities thatdifferentiate these states and identify the threatening other. This happens inmultiple fields of human activity, and exploring all of these would require muchmore space than I have here. In this paper, I restrict my focus to two fields ofpractice that have played a prominent role in the production of the state system:the regulation of health and human movement.

A second contribution of this paper to the study of the production of insecu-rity is to further explore the relationship between public and private actors inthis process, which has emerged as one of the central themes around which thefield of security studies is organized (Williams 2010). Though the institution andbundle of practices known as the state is a primary site where insecurity is pro-duced (Weldes 1999:18), critical security scholars have drawn attention to howactors such as the media (Shapiro 1997; Williams 2003; Hansen 2007; Weber2007; Huysmans 2010), private security firms (Leander 2005; Abrahamsen andWilliams 2009), and specialized security bureaucracies and intellectuals(Luckham 1984; Cohn 1987; Dalby 1990; O’Tuathail and Agnew 1992; Bigo2002) reproduce state-based discourses of danger. In this paper, I draw on theCanadian case to show how the migration and health bureaucracies of the stateand private travel insurance corporations reproduce the international ⁄ nationalbinary and construct the national ‘‘self’’ through the regulation of cross-bordermovement and contagious disease. I focus on these actors to further demon-strate the myriad sites in which security is reproduced, and because they are priv-ileged in the production of insecurity in this particular domain even as theyremain under studied in the field of security studies.

Contagious Disease and Migration in the Study of Insecurity

Most scholars addressing the construction of insecurity associated with conta-gious disease and migration examine them separately, though this article takesup Mary Douglas’ call to study classifying symbols not in isolation, ‘‘but in rela-tion to the total structure of classifications of the society in question’’ (Douglas1966:vii) that include international and national, secure and insecure, clean anddirty, rational and irrational. Nonetheless, it is useful to examine how theseissues have been incorporated in security studies. As with many other ‘‘new’’threats, contagious disease has been brought into the field of security studies bythose seeking to broaden the field beyond military security. Problematically,these security broadeners tend to treat disease as an objective threat to eithernational or human security. For example, some security scholars (Lillibridge2000; Peterson 2002; Price-Smith 2002) contend that epidemic disease endangersnational security because it induces violent conflict or reduces the ability of themilitary to defend the state. Alternatively, human security scholars (UNDP 1994;Rothschild 1995; Paris 2001) contend that disease is a threat, not because it

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contributes to the outbreak of violent conflict, but because of the sheer numberof preventable human deaths they cause. While usefully identifying some of thepractical problems posed by contagious disease, the broadeners neglect the pro-found implications of treating it as a security issue. For instance, Fidler (2007)demonstrates that the securitization of health-related issues since the end of theCold War challenges alternative, more productive strategies for the provision ofhealth and humanitarian assistance. Others (McInnes and Lee 2006; Davies2008) point out that the recent securitization of health has produced aninternational health regime that prioritizes the interests of Western states.

The importance of these de-securitizing works lies in showing how the securiti-zation of infectious disease has contributed to unexpected, negative outcomes;issues often overlooked by proponents of broadening the security agenda.However, the de-securitizing critique ignores how disease functions as aboundary-defining concept and how the securitization of infectious disease is afoundational component of the identity of individual states and the state system.It is not a new, nor a post-Cold War phenomenon; it has been an integral partof the nation-state building process since its inception. In Western states, healthof the population is an important component of the nation’s identity, andproviding protection against the diseased other a key role of the state andinternational entities. That this manifests itself in the intensified securitizationfollowing the end of the Cold War, and the privileging of certain states shouldnot come as a surprise.

Provision of healthcare is an integral component of Canadian identity2 andother Western states and is produced through the identification of locations ofdisease and vulnerability against which the state must be secured. Consequently,migration into and out of the state becomes a source of insecurity, as citizens ofthe secure state are exposed to dangers associated with foreign spaces either viaimmigration or through international travel. The regulation of health and cross-border movement represent distinct strands of a larger set of practices thatreproduce national ⁄ state identity and the dangerous other, in turn reifying theterritorial nation-state as the natural, safe and secure mode of organizing theanarchic and dangerous international realm.

Migration has also been drawn into the realm of security studies, most notablyfollowing the restrictive turn in immigration policy in Western states after the ColdWar (see Wæver, Kelstrup, Lemaitre, and Buzan 1993; Weiner 1995; Doty 1996;Bigo 2002; Huysmans 2006). Much of this work addresses how migration has beenperceived as a threat to societal identity, demography, or culture, exemplified bythe rise of xenophobic, anti-immigrant parties and social movements and theincreased surveillance of certain minority groups. Fears over the cultural impact ofmigration are intertwined with other distinct concerns as well, such as public orderand labor market stability (Huysmans 2000:752). Huysmans (2000) contends thatthese three interrelated concerns play an integral role in the Europeanizationprocess and the identification of Europe as a distinct political community.

In this paper, I point to a fourth concern that is inter-twined with migrationand the production of identity and insecurity—that of health and disease. Asnoted earlier, health is a key component of national identity and converges ontwo axes of differentiation: culture ⁄ race and just desert based on contribution.Identification and exclusion of the other is based on dual claims: that othercultural practices are unhealthy and need to be kept out of the healthy body

2For example, the Romanow Report concluded that ‘‘Canadians still strongly support the core values on whichour health care system is premised—equality, fairness and solidarity. The values are tied to their understanding ofcitizenship’’ (Romanow 2002:xvi). More recently, the Conference Board of Canada 2010 Report noted that ‘‘Of allCanada’s social policies, the health care system is the most prized, and is central to Canadians’ views of what isnecessary for a high quality of life’’ (Conference Board of Canada 2010:78).

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politic (Douglas 1966) and that the welfare state requires protection through theexclusion of those who have not contributed to it or who endanger it. These twomutually reinforcing concerns are evident in the processes that gave rise to themodern nation-state in Europe.

Health, Migration, and the Nation-State

Fear of contagious disease was a key element in the process of establishing theWestphalian nation-state order. Political authorities in the early modern periodsought to control the spread of contagious disease through the implementationof emergency measures targeted toward migrants. Practices such as quarantine,sequestration of infected property, and the establishment of cordons sanitaires tar-geted migrating populations and were designed to prevent the spread of disease(La Berge 1992:10; Sehdev 2002). As a result of repeated bouts of contagious dis-ease, these emergency measures gave way to more permanent institutionalizedmeasures in the form of boards of health and legal requirements governingvarious ‘‘health-related issues’’ such as street cleaning and sewage disposal(La Berge 1992:21; Palmer 1993:66). The early bureaucratization process aroundthe issue of health was key to the emergence of the nation-state as the preemi-nent political authority in Europe.

The expanding bureaucracy of the state also sought control over human move-ment. John Torpey demonstrates that states sought to monopolize the capacityto authorize the movement of persons to extract military service, taxes, andlabor; to control the loss of labor and brain drain; and for the exclusion, surveil-lance and containment of undesirable elements of ethnic, national, religious,ideological, and medical character (2000:7). The multitude of undesirable andthreatening ‘‘others’’ served to justify the expanding bureaucratic control overhuman migration through the use of passports and other identity documents.The early modern state’s growing control over the legitimate use of violence andthe monopolization of the means of production were made possible partlyby the elaborate bureaucracy devoted to controlling and limiting human move-ment (Torpey 2000:167). As the nation-state emerged as the legitimate form ofpolitical community in Europe, two of its primary rationales, and among its mostdeveloped permanent institutionalized presences, concerned the regulation ofhealth and human movement.

The link between the threat of infectious disease and migration, and the needfor state control, was further cemented during the period of European imperial-ism, when contagious disease was most clearly associated with the colonized pop-ulations in the tropics. David Arnold argues that as European powers came intocontact and established relations with the colonized other, medical establish-ments in Europe developed a discourse of tropicality, creating a sense of other-ness that Europeans attached to these environments as distinct from their owntemperate zones (1996:6–7; see also Bankoff 2001:20–21). Subsequent scientificresearch into distinctions in plant and animal life, climate and topography,indigenous societies and their culture, as well as the nature of disease served toreinforce the tropical ⁄ temperate distinction (Bankoff 2001). Western medicaldiscourse and practice effectively defined large portions of the earth as zones ofdanger for Europeans and large portions of the earth’s population as dangerousbased on race, culture and geographic location. Though much of the scientificbasis of the tropicality narrative has been replaced, and other discourses of dan-ger now supersede fears of tropical disease; it has not been completely eclipsedas a boundary-defining concept. Western governments still issue health, travel,and vaccination warnings to their citizens and impose quarantine on goodsand people from certain regions perceived as dangerous (Bankoff 2001:21;Lowenheim 2007:203).

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Awareness of the danger associated with tropicality gave rise to a greater con-cern with health and hygiene as an integral component of Western identity; aprocess Michel Foucault referred to as the ‘‘imperative of health’’ (Foucault1980). In her work on public health, Deborah Lupton argues that the healthand hygiene movements of the nineteenth century were about reproducing theboundaries between included and excluded populations, and about preventingcontamination of those within from those without (1995:38). Immigration in par-ticular was a site of potential vulnerability; immigrants were often viewed as athreat to the health of nations, and as foreign agents, like bacteria, seeking toinvade and occupy the healthy body politic (Lears 1989:60; Sears 1992:70). Inmany Western states, disease outbreaks were blamed on immigrant or minoritycommunities, such as Jews throughout Europe, Chinese immigrants in Australiaand Canada, Italian immigrants in New York City, to name but a few (Lupton1995:31–44). In Britain, immigrants from tropical areas of the empire wereexcluded on the grounds that they were dirty, contaminated, did not conform toWestern ideas of sanitation, and would produce moral decay (Doty 2003:250).

In Canada, policies aimed at preventing contagion were bound up with racial-ized fears of immigration and border control (Mawani 2003:3). The colonialdepiction of certain areas as ‘‘reservoirs of disease,’’ or ‘‘plagued by illness andcontagion’’ justified the exclusion of people from these areas (Mawani 2003:8).The discourse of tropicality combined race ⁄ culture and health as distinct compo-nents of national identity, identifying external diseases as more threatening andthereby legitimizing efforts of the state to promote and ensure the health of itscitizens by excluding certain races through various restrictive immigrationcontrols.

Even as Canada and other settler states, such as the United States and Austra-lia, abandoned their explicitly racist immigration policies, the discourse oftropicality continued to play a role in reproducing national identity and infor-ming immigration policies (Bankoff 2001). The contemporary manifestation ofthe dangers associated with tropicality is evident in the border control and visapolicies of Canada and other Western states. The Canadian government main-tains a designated unhealthy country list and requires a medical examinationfrom residents or long-term visitors of those areas. A quick examination of theseterritories reveals that most of Africa, the Middle East, Asia, and South Americaare considered dangerous zones.3 Migrants from these areas are not prohibitedfrom entry, but must first alleviate Canadian suspicions by submitting to a medi-cal exam at an approved medical office. Thus, as Lupton notes, the practicesand discourses of Western states have drawn upon certain binary oppositionssuch as inside ⁄ outside, clean ⁄ dirty, healthy ⁄ diseased, safe zones ⁄ zones of dangerwhich legitimize discriminatory moral judgments by identifying groups at riskand in need of protection and groups that pose a risk and thus require extrasurveillance and control (1995:47). Beliefs about contagion from immigrantsuphold moral values about who deserves health and social services that in turnjustify practices of exclusion (Douglas 1966:3).

In Canada, potential migrants may be excluded for various reasons beyondfears of contagious disease—criminality, membership in a violent organization,physical ⁄ mental disorder, or insufficient financial support (CIC 2009). Each ofthese categories of difference reflects distinct moral bases on which Canadiannational identity is reproduced and through which exclusion is necessitated. Anumber of these exclusions, such as those with insufficient financial resourcesand those with contagious disease, partially reflect a concern with the mainte-nance of the welfare state and the prosperity of the country. Foucault notes that

3The full list of countries ⁄ territories and approved medical offices is available at http://www.cic.gc.ca/english/information/medical/dcl.asp.


this has been a concern of states since the eighteenth century and gave rise tohealth policing in that era (Foucault 1980; Turner 1997). Health, economic pros-perity, and national security became intimately intertwined as the citizenry’shealth, wealth, and longevity emerged as the greatest resource of the state(Rosen 1953; Osborne 1997:177–178; Lowenheim 2007:205). Over time, the viewof the healthy citizen as strategic resource for the state was supplemented by theview that citizens had a right to good health in the eighteenth century and there-after, public health became the duty of the state and a proper area for interven-tion and control (La Berge 1992:16). Health and the provision of healthcare bythe state as a marker of difference internationally blossomed with the birth andgrowth of the welfare state. Though contagion from foreigners continues to beunderstood as a threat to the health of society, it also increasingly reflects a con-cern with the protection and security of the public health system itself. To takeone contemporary example, Citizenship and Immigration Canada (CIC) subjectscertain migrants to health checks ‘‘to protect the health and safety of Canadiansand to reduce and prevent excessive demand on Canada’s health and socialservices’’ (CIC 2010c).

Protection of the social safety net in the modern nation-state is necessitated bythe crucial role it plays in legitimizing the state (Beck 2002:40–41). In Canada,as in other Western states, the two dominant features of the welfare state are toprotect citizens from poverty and disease,4 and these dangers are, in turn, associ-ated with foreign spaces and migrants. Excluding poor and diseased migrants,who are expected to make immediate and costly demands on the welfare state,reproduces national subjects as legitimate recipients of such assistance and theperception that potential migrants are illegitimate recipients. The moral basis ofexclusion incorporates beliefs about contagion as well as beliefs about justdeserts based on contribution. Externally, the undeserving migrant is justifiablyexcluded through the representation of them as profiteers gaining benefits andsecurity from the welfare system of a community to which they do not belongand have not contributed (Huysmans 2000:768). The internal manifestation ofthe just deserts moral basis of exclusion is the ‘‘welfare cheat’’ (see Cruickshank1997; Moffatt 1999; Chunn and Gavigan 2004).

The construction of the undeserving migrant motivated to cross internationalborder to gain access to the social safety net of Western states also serves to rein-force another aspect of the Western state identity: the Western welfare statemodel as the exemplar of good governance and rationality. Equating theWestern world with the civilized world is a prominent boundary condition differ-entiating the West from the rest based on features of Western states such as dem-ocratic ideals and rationality (Tsoukala 2008:147–148). I would add that thewelfare state and modern medicine serve as similar function as democracy, as aboundary through which the West is reproduced as civilized and rational. In thisconstruction, weak social security provisions and an unhealthy citizenry reinforcethe tropicality discourse that constructs certain areas as less developed, culturallyunhealthy, and potentially dangerous. The representation of certain parts of theworld as prevalent with disease in the media (Youde 2005) or in UN documentssuch as the Human Development Index reinforces the conception of the West asadvanced, rational, and desirable, and other areas as backward, irrational, andundesirable. In turn, nationals of these states ⁄ zones are thereby constructed asthreatening, by their potential to flood or invade the developed Western statesand overwhelm their social safety nets (Faist 1994:61), and by their backward orirrational cultural characteristics (Youde 2005) that threaten the rationality onwhich the welfare state is based. This in turn necessitates and legitimizes the

4In Canada, ‘‘social services’’ is the largest government expenditure (26% of budget), while ‘‘health’’ is second(20%) (Statscan 2010).

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creation and maintenance of designated lists to identify and exclude unhealthy,and thus potentially dangerous, zones and peoples.

The Regulation of Human Movement into and out of Canada

Regulating cross-border movement is among the most conspicuous ways statesdemarcate the domestic and orderly from the international and anarchic. Thisis achieved partially by identifying and keeping out that which is viewed asdisruptive of the domestic order. For instance, border control officers in Canadaidentify and prevent the inflow of inadmissible people, illegal goods, dangerousplants, and animals, as well as dumped and subsidized goods (CBSA 2010). Eachof these categories of exclusion reproduces the ordered ⁄ anarchic binary; thoughI am concerned here with the regulation of human movement for reasons ofhealth security. As noted earlier, the Canadian state identifies certain regionsand populations as potential health risks and presents the state as the guarantorof security against those risks. Canada’s border services agency is tasked with pre-venting the inflow of inadmissible people, which includes those who have ahealth condition that is likely to be a danger to public health, to public safety orthat might reasonably be expected to cause excessive demand on health or socialservices (CIC 2006:24). In instances where the security and border control func-tions of the state break down, such as the arrival of unauthorized migration, CICreassures the Canadian public that all unauthorized migrant arrivals are requiredto undergo health checks prior to their release into the community (Mountz2004; Watson 2009).

To identify inadmissible or risky populations whose movements are subject togreater regulation and surveillance, Canada and other Western states rely heavilyon medical experts. Though mostly neglected in security studies, medical expertsfigure prominently in the field of critical health research (see Osborne 1993;Lupton 1995; Peterson and Bunton 1997). Bunton contends that the growingimportance and influence of medical experts is part of the expansion of themodern liberal state, as political authorities utilize and instrumentalize forms ofauthority and expertise outside of the state apparatus through processes oflicensing and bureaucratization (1997:224). These medical experts play a crucialrole in the construction of health risks—not unlike other specialized securityagencies that are charged with protecting the state from various security risks,such as migration, terrorism, criminality, and military conflict.

In Canada, the Public Health Agency of Canada (PHAC), and its sub-agencythe Canadian Committee to Advise on Tropical Medicine and Travel (CAT-MAT—note again the concern with tropicality), is the expert agency tasked withidentifying dangerous, unhealthy populations and regions. CATMAT is made upof health intellectuals that include prominent doctors from various hospitals andhealth authorities around the country, representatives of medical associationssuch as Medical Microbiology and Infectious Disease, Pediatric Society, andEmergency Physicians, from the International Development Research Centre,Canadian Public Health Association, the Centers for Disease Control and Preven-tion, the World Health Organization (WHO), as well as Ministries of Healthfrom other states. CATMAT advises PHAC, which in turn advises various govern-mental bodies and the Canadian public on the dangers associated with certainparts of the world, with certain diseases and with certain behaviors, ranging fromsexual practices to international adoption. CATMAT also includes the RoyalCanadian Mounted Police, the Department of National Defence, and CIC, rein-forcing the connection between international travel, health and the securityof the Canadian body politic. The expert knowledge produced by PHAC andCATMAT forms the basis on which the federal government, the CIC and the Cana-dian Border Services Agency (CBSA) make decisions regulating inadmissibility


(which diseases qualify as a risk to public health, public safety, or excessivedemand), which countries require visas and medical examinations, how long todetain unauthorized arrivals and who to quarantine and for how long.

These medical experts and bureaucracies also help to regulate human move-ment out of Canada through the production of ‘‘insecurity texts,’’ such as travelreports, travel health notices, and advisories. According to Lowenheim (2007),the primary function of these texts is to responsibilize international travelers byidentifying threats to the Canadian traveler and prescribing appropriate behav-ior. PHAC uses a four-point system to identify zones of danger, which corre-spond to the severity of risk posed and the type of behavior regarded asresponsible: (1) practice usual precautions; (2) practice special precautions; (3)avoid non-essential travel; and (4) avoid all travel. According to PHAC, the deci-sion to issue a warning takes into consideration a variety of factors, includingstandards of hygiene and sanitation, availability of safe food and clean water andclimate or environmental conditions that support diseases that do not occur inCanada (PHAC 2010). Employing Canadian standards of hygiene and health toestablish the level of threat posed by other regions clearly reflect the ongoingimportance of tropicality as a boundary producing narrative (Arnold 1996;Bankoff 2001).

The behaviors prescribed in these advisories reflect the level of perceivedthreat to both the international traveler and the non-traveling Canadian public.In levels one and two, the traveler is the entity that is threatened and responsibil-ity for the individuals’ well-being rests with the individual herself. In levels threeand four, the Canadian public and the international traveler are threatened bythe traveler’s decision to leave the safe and secure domestic space, and the inter-national traveler is responsible for their own security and the security of theCanadian public. As Lowenheim (2007) notes, these advisories function toresponsibilize international travel by advising against travel, but they do muchmore than this, they also reproduce the international ⁄ domestic binary that formsthe basis on which the necessity for the state rests, with the Canadian state serv-ing as the authoritative source on everyday dangers and responsible behaviorand as the safe and secure location for Canadian citizens.

The Department of Foreign Affairs and International Trade (DFAIT) producesa similar insecurity text and issues travel reports and warnings based on a varietyof risks, such as weather, political upheaval, criminal activity, and terroristattacks. Like PHAC, DFAIT employs a four-scale system, ranging from (1) exer-cise normal security precautions; (2) exercise high degree of caution; (3) avoidnon-essential travel; and (4) avoid all travel. Not surprisingly, most of the mostdangerous rankings are concentrated in Africa, Southern Asia, the Middle East,South America, and Eastern Europe. Just as telling, perhaps, is the lowest traveladvisory that is visited on the United States and Western Europe—‘‘exercise nor-mal security precautions.’’ Even these safe zones are presented as potentiallydangerous, and the responsible Canadian traveler is reminded to exercise ‘‘nor-mal security precautions.’’ Once again, this description demonstrates the state’sefforts to responsibilize the traveler (Lowenheim 2007:205) while reproducingthe international realm as anarchic and dangerous. All foreign spaces, and thustravel, are potentially dangerous, which reinforces the production of the homestate, Canada, as a safe and secure location for the modern, national subject.

Regulating Healthcare in Canada

The regulation of healthcare serves a similar function and includes defining whatqualifies as healthcare and who has access to it. State regulation of healthcareprimarily consists of maintaining the medical infrastructure and delegatingpowers of health to an accredited medical profession (Osborne 1997:183). A

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foundational component of this system is to define experts and expertise as itrelates to the modern practice of medicine (Johnson 1993:150). This systemdecides what qualifies as medical care by identifying and excluding that which istraditional, alternative, or non-conventional—and thus excluded from publicinsurance coverage. It also defines who is a qualified medical practitioner. Thesepractices necessarily exclude a range of practices and actors, often associatedwith the ‘‘foreign’’ other; whose expertise is not recognized as sufficientlyscientific or rational to qualify as medical care in the modern, Western sense. AsLupton (1995) notes, the public health discourse in Western states produces awide range of binary oppositions associated with discriminatory moral judgments:including the mind ⁄ body, healthy ⁄ unhealthy, rational ⁄ irrational, disciplined ⁄self-indulgent, clean ⁄ dirty—oppositions that often overlap with and reproducethe inside ⁄ outside, self ⁄ other, and domestic ⁄ foreign. In these representations,traditional or non-Western modes of healthcare are regarded as non-scientific.This is simultaneously reinforced through the construction of certain regions ofthe world as irrational, unscientific, or medically incompetent. For instance,Youde observes that in Western countries, southern Africa is presented as boththreatened by HIV ⁄ AIDS and also as partially responsible due to certain culturalpractices and the apparent rejection, incomprehension or misunderstanding ofbasic scientific facts about the AIDS virus (2005:203).

Consequently, the Canadian healthcare system is a boundary reproducingpractice that differentiates between the rational West, and non-rational regionsof the world. In turn, the healthcare system is portrayed as needing protectionfrom non-rational modes of medical expertise even as medical capacity, andexpertise in foreign spaces is simultaneously demanded and questioned. This isperhaps best illustrated through the process of recognizing the foreign medicalcredentials of international medical graduates (IMGs). The Foreign CredentialRecognition Program set up and run by CIC provides funds for the recognitionof foreign medical credentials, which is administered by the Medical Council ofCanada and the Physician Credentials Registry of Canada. This process allowsthe state and the accredited medical profession to evaluate the medical compe-tency of IMGs and to determine whether they need to upgrade their training ina Canadian medical program. According to the Medical Council of Canada,IMGs seeking to practice medicine in Canada need to: verify their medicaldegree is from an approved university, pass the MCC Evaluating Examination,the MCC Qualifying Exams, provide proof of language proficiency, complete aminimum of 12 months of supervised clinical training, in addition to any furtherprovincial requirements (MCC 2010). Here, we witness the Canadian stateattempt to maintain order, safety, and the rational ⁄ scientific basis of the Cana-dian health system as it comes into contact with the anarchic, disordered, andirrational international realm as represented by IMGs.

The international realm is further reproduced as anarchic and disordered byvirtue of the perception that Canadian healthcare is in high demand and acts asa pull factor for many migrants. In a document entitled ‘‘Deterring Individualsfrom Coming to Canada as part of a Human Smuggling Operation,’’ the CIC(2010a) asserts, ‘‘Canadians enjoy health services that are among the best in theworld. However, it is unfair that those who have not followed the rules berewarded for their crimes by having access to more generous benefits that theaverage Canadian receives.’’ In a subsequent document, the CIC directly tiesaccess to healthcare to illegal entry, asserting the government will: ‘‘reduce theattraction of coming to Canada by way of illegal human smuggling by ensuringhealth benefits participants receive are not more generous than those receivedby the Canadian public’’ (CIC 2010b). The construction of Canada’s healthcaresystem as the envy of the world serves to reinforce suspicions of migrants asunhealthy and to justify increased surveillance on these populations.


The moral bases of exclusion rest on both the need to protect a rational,scientific healthcare system, and on that of just deserts. Those that have not, orcannot, contribute to the system are excluded. As was raised in previous sections,people with severe health problems are denied visas for entry to Canada, notbecause they do not need care but because as non-Canadians they have not con-tributed to the creation and maintenance of the Canadian healthcare system.Thus, the Canadian state attempts to exclude these people while they are stilloutside the state. Inside the state, accessibility to healthcare reflects a hierarchyof exclusion partially based on just deserts. The primary mode of exclusion restswith eligibility for public medical insurance, which is a provincial responsibility.Though eligibility for public insurance varies across provinces, there is a hierar-chy of eligibility based on contribution to the system. In all provinces, Canadiancitizens and permanent residents are eligible for public insurance, subject to pro-vincial exclusions—Canadians who do not physically reside in the province5 maybe ineligible for public insurance in that province,6 as are out-of-province stu-dents. For Canadians taking up residence across provincial borders, there areshort waiting periods to establish eligibility. The inter-provincial distinctionsbetween eligible and ineligible groups reflect a concern with just deserts—tohave access, one must have resided in that province long enough to contributeto or signal an intention to contribute to the maintenance of that provincialhealthcare system.

Similar concerns are evident in the case of non-permanent residents withinCanada. Visitors are completely excluded under provincial plans, as are refugeeclaimants—though they are eligible for limited essential-health services throughthe Interim Federal Health Program (Gagnon 2002). Foreign students are ineli-gible in some provinces; in others, they are subject to waiting periods rangingfrom 3 months to over a year; while those in Canada on work permits are eligi-ble in all provinces after a waiting period between one and 3 months (Gagnon2002:36). Those who are perceived to contribute least (visitors, refugee claim-ants, and students) are excluded, given limited access or subject to greater waitperiods, while those who contribute most (citizens and permanent residents,foreign workers) are eligible in a short time. At a very basic level, regulation ofhealthcare through public insurance in Canada establishes a typology ofinclusion ⁄ exclusion that rests on moral considerations of maintaining orderof the system and just deserts based on contribution to the system.

The Technology of Insurance

Access to public insurance is the primary technology through which the Cana-dian state regulates access to healthcare, which in turn reproduces the insecurityassociated with foreign spaces, people and disease essential to the legitimation ofthe state. The importance of insurance in modern societies is a central theme ofUlrich Beck’s work on risk society, and he argues that ‘‘uncertainty and insecu-rity is produced in every niche of modern existence, and security against suchuncertainty is essentially stitched together out of a combination of public andprivate insurance agreements’’ (Beck 1992:100). This is evident in the case ofhealth security in Canada, where the costs of health security are split 70–30between public and private insurance schemes (Government of Canada 2004).The prevalence of public and private insurance as modes of providing security inmodern states has led Francois Ewald to conclude that societies are constitutednot in accordance with wider political or cultural principles, but as vast systems

5What qualifies as residing differs between provinces, but usually requires having their primary home in theprovince, and living in that province for half of the year.

6Though they will not be denied care, the cost must be covered by the individual’s home province.

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of insurance (1991:210). While this conceptualization of the state ignores theinternal ⁄ external dynamic and the role that identity plays in excluding humanpopulations from inclusion in such insurance protections, Ewald’s broader con-tention about insurance as a socio-political arrangement is important—insuranceoperates on logic distinct from that of collective identity in that it conceptualizesrisk and insecurity as calculable (evaluates probability), capital (rectifies financialrepercussion of loss, not loss), and collective (applies only to groups) (Ewald1991:201). For the purposes of this paper, the collective is the most significantcomponent. Insurance as a technology of risk relies on the establishment of acommunity through the pooling of contributions of individual members and theredistribution of costs associated with the risks of life in modern societies. Theimportance attached to the collective and the redistribution of cost leads Ewaldto conclude that the logic of insurance is fundamentally about justice andsocial redistribution (1991:202–203; see also Elbe 2008:186). Public insurance isfoundational to the formation and continuation of the state’s population as arelevant human collective, bound together by mutual insurance agreementsaimed at social redistribution within that group. In turn, the state, which pro-vides security (and some measure of justice) through the social redistributionassociated with social insurance, guarantees its own existence, since the techno-logy of risk and insurance ‘‘requires permanent institutions with quasi-infinitelongevity’’ (Ewald 1991:209).

With the advent of neo-liberal economic policies and the increasing individ-ualization of healthcare responsibility, states and their citizens increasingly turnto private insurance to buttress the public system, in the process empoweringprivate corporations in the construction of discourses of health risk (Nettleton1997:217; Petersen 1997:194–195). Anna Leander notes that this process is evi-dent in ‘‘traditional’’ fields of security as well, where private military corpora-tions not only reproduce state-based narratives of insecurity from which theyprofit, but also increasingly define what constitutes a security threat withinthose narratives (Leander 2005:814). State-based discourses of danger or riskcombined with increased privatization and commodification of security expandthe scope and power of private corporations to influence the discourse andpractice of security and profit from it. This is not to say that the interests ofthe state and private corporations are identical; private and public corpora-tions do often come into conflict, but private corporations often act in thespaces created by state-based institutions; thus, their concerns and activitiessupport the imperatives of the state (Lupton 1995:9). For instance, Lowen-heim identifies how insurance corporations engage in the state’s efforts toresponsibilize travelers by denying coverage (2007:217) while Claudia Aradauand Rens van Munster demonstrate how insurance companies support thestate’s efforts to order a future of precariousness, threat, and uncertainty(2008:192).

Consequently, a certain level of security against sundry dangers of modernity isfounded on the perfection of techno-bureaucratic norms and controls of thewestern welfare state (Beck 1992:104); yet, the state is not the sole social insureragainst insecurities associated with the rise of modern capitalist system (Aradauand van Munster 2007). The provision of security in Western states is best under-stood as a public ⁄ private partnership—though the balance between the two var-ies between and within societies. In this partnership, private corporations fill inwhere public systems cannot or will not provide protection. Noting the increasedprevalence of private security arrangements, Aradau and van Munster contendthat the role of private insurance corporations and private security arrangementshas expanded as principles of neo-liberalism relocate responsibility from the col-lective (social solidarity) to the individual (Aradau and van Munster 2007:100;see also Petersen 1997:194).


This development raises an important concern about the privatization of secu-rity: for whom should protection be provided and who qualifies to partake in thesocial redistribution of harms and goods? For state-based security arrangementsthat operate on the insurance model, the community is the state’s population,and social redistribution occurs within that community—to the exclusion ofthose outside. With private insurance, the community is simply the communityof consumers who can afford coverage, with individuals responsible for their ownsecurity. As greater emphasis is placed on individuals to provide for their ownsecurity via insurance, society moves from the social redistribution of harms andsocial goods associated with public insurance. Those who can afford privateinsurance are protected against a wider array of hazards and insecurities associ-ated with modern living than those who cannot. For proponents of public socialinsurance, this is a powerful argument. However, viewing state-based security aspreferable to privatized security need not accept or present it as an idealizedfinal condition. As the paper has argued throughout, this conceptualizes thestate as the institution that preserves its citizens’ welfare and security by enforc-ing order on the inside and warding off threats emanating from the anarchicinternational system (Browning 2003:557). Preserving the security of the welfarestate prioritizes the health and wealth of citizens over that of excluded people.In doing so, it is used to justify the detention, deportation, and surveillance ofexcluded groups.

Travel Insurance

The choice to cross an international boundary is represented as an inherentlyrisky proposition, a location where the home state is incapable of enforcingorder or providing protection (Salter 2003:4). Here, individuals are expected tobe responsible and insure themselves against possible dangers, in the form ofvaccinations, health and travel insurance.The travel insurance industry identifiesvarious types of risk associated with international travel, not merely filling in thegap left by the state’s insecurity apparatus (social insurance), and they areempowered to identify risks as well as appropriate solutions. As Stephan Elbe(2008) argues, insurance companies point out all the dangers that might befallpeople and identify the proper instruments to manage those risks, though theydo not do so freely—there are potential risks everywhere, some are accepted,others are not (Ewald 1991:225). Insurance corporations make risks appearthrough the categorization of new and old developments as risk that can bemanaged and controlled, rather than as chance or fortune (Ewald 1991:200). Indoing so, they draw on and reproduce existing identity constructs and identifydevelopments that may threaten that identity. Travel insurance then provides anopportunity to examine identity constructs, and the types of developments thatare constructed as risky and dangerous. Though there are myriad identity con-structs that are reproduced through this institution, I focus on the themestouched on earlier in the paper: the national, healthy, modern self.

Current practices associated with the provision of medical care reinforce theconstruction of foreign travel as a health risk common sense for most Canadians.While in Canada, residents of Canada pay approximately 30% of their healthinsurance costs (Government of Canada 2004); when outside of the state, theyare responsible for close to 100% of the costs. This is a feature that travel insur-ance corporations repeatedly emphasize. In the travel insurance materials of fourof the leading Canadian travel insurance corporations,7 consumers wereconstantly informed that their medical costs while traveling are not covered byprovincial medical plans—and furthermore—that these expenses represent a

7I examined RBC Insurance, TD Insurance, Great Western Life, and Blue Cross.

171Scott Watson

financial risk. One plan, for instance, informs, ‘‘provincial health plans cover<7% of total costs of getting sick or injured.’’ Another notes that ‘‘the BCgovernment pays only $75 a day for hospital care, while the average cost in UShospitals exceeds $1,000 and can be as much as $10,000 per day in intensivecare.’’ A third advises ‘‘daily hospital room rates average $5,000 in the USA andair evacuations from the Caribbean average $17,500.’’ One travel insurance pro-vider documents actual cases and costs to remind consumers of the potentialcost of not having coverage. The three listed included ‘‘a motor vehicle accident(19 days in hospital—$451,380), a cardiac bypass (13 days in hospital—384,275 +19,875 air ambulance) and a fractured femur (6 days in hospital—$58,825).’’

The information presented reminds consumers of the safety of the home state(where such costs are covered) and the risky nature of international travel. AsElbe (2008) notes, these companies present worst case scenarios associated withinternational travel and then present the insurance packages they offer that willreduce these risks. In this construction, the nation state is the location of safety,order, and security, where public health insurance ensures that normal everydayhealth issues do not produce heavy financial loss. Yet, it is important to note thatthis type of insurance, in Michael Dillon’s (2007) words, secures through contin-gency. The conventional understanding of being secure from the vicissitudes ofcontingent being is now portrayed as a form of insecurity, a way to kill off exis-tence (Dillon 2008). Experiencing international travel in certain parts of theworld, including Canada, is constitutive of living a full and rewarding existence.Life in contemporary modern societies is often thought of in terms of the placesone travels to and experiences before death; indeed, many people draw up listsof places they want to see before they die as a means of measuring the successand value of their life. To secure oneself against the hazards of the internationalby not traveling is to kill or limit the self. This representation presents the nationstate as ordered and secure, and in turn, its order and security as threatening.To live the fulfilled life, one must be exposed to risk and insecurity, whichcan be accomplished by leaving the nation, and exposing oneself to the dangersof the international realm. Importantly, these dangers are mitigated andmanaged through various technologies made possible only through the homenational-state: the passport, consular services, and eligibility for travel insurance(Lowenheim 2007). The security in being a national being is what makes the riskand insecurity of international travel tolerable. To put it succinctly, statelesspersons experience international travel in a fundamentally different way thanthe modern, national being.

Travel insurance reproduces the international as dangerous and anarchic, butthat experiencing travel is essential to living a fulfilled life. Consequently, itaffirms the importance of travel to modern life as it reminds customers that:‘‘you’ve been dreaming about your vacation for years’’; ‘‘you’ve saved your hardearned dollars and want to experience the time of your life’’—even as it providesprotection against the dangers associated with living a full life. Travel insurancecorporations profit by reminding consumers of the vicissitudes of contingentbeing and offering protection against them. The inherent risk of travel in themodern world is a common theme in travel insurance industry: ‘‘your two weekvacation budget can easily be blown by something as simple as food poisoning, adental cavity or appendicitis’’; ‘‘even a cross-border day trip to the USA canquickly turn into a financial or medical nightmare’’; and ‘‘an accident, illness, oremergency can happen anywhere.’’ These examples demonstrate how mundaneand fairly normal occurrences (food poisoning, dental cavities, a day trip) turninto high-risk activities that represent a threat by virtue of the international bor-der. Again, the dangers are emphasized ‘‘travel can mean encountering theunexpected—ranging from the inconvenient to the truly serious.’’


Though the focus of travel insurance is on the health and financial risks asso-ciated with crossing borders, the travel insurance industry identifies a wide rangeof risks associated with international travel. The potentialities against whichCanadians can purchase insurance include: emergency hospitalization or medicalservices while traveling, cancelation of trip due to illness, transportation of familyor friend to your hospital, need to return home early for family emergency,return from emergency to trip destination, pet return, return of deceased, acci-dental dental and dental emergencies, emergency transportation, missed flightor connection, lost luggage, accidental death or dismemberment, flight accident,trip interruption or cancelation, government issued travel warning, cruise ⁄ tourcompany bankruptcy, return of vehicle, and rental vehicle damage protection.8

The expanding list of risks associated with international travel testifies to themyriad elements of normal, nationalized life that become problematized byvirtue of crossing an international border as well as the way in which insurancecorporations identify developments that can be categorized as risk and financiallysecured through the technology of insurance.

Private travel insurance corporations operate within and reinforce the state-based construction of the international as an insecure location and profit from itby identifying various types of risks associated with life outside the protectionsof the modern territorially defined state. The production of health insecurityassociated with international travel reinforces the importance of the state in theprovision of security, but also identifies the limits of that protection at theborder.

Conclusion

The reproduction and maintenance of national boundaries demonstrates thatinsecurities associated with international anarchy are not natural and inherent toan anarchic system, but have a history and are the product of human agency.But it is not clear that this anarchic system is ‘‘what states make of it’’ (Wendt1992), as much as it suggests that differentiated nation-states require a danger-ous and disordered anarchic international realm to necessitate the production ofdomestic order and security. Exclusion is an essential feature of such a system,and as Douglas contends ‘‘it is only by exaggerating the difference betweenwithin and without, above and below, male and female, with and against, that asemblance of order is created’’ (1966:4). Playing slightly with Douglas’ conten-tion, this article has shown that it is only by exaggerating the differences betweenwithin and without that disorder is created, and the attempt to create ordernecessitated. Anarchy and state identity are mutually coconstitutive; states andprivate actors rely on and reproduce international anarchy through the mainte-nance of collective boundaries and national identities.

The regulation of human movement and health are two fields of practicethrough which the international ⁄ domestic is actualized, and which reinforce themoral bases of exclusion fundamental to the nation-state. These twin concernshave been an integral element of the growth of the nation-state as the pre-emi-nent form of political community. The Canadian case demonstrates that theidentity of the national self has been constructed in difference to the unhealthy,non-Western, and undeserving outsider, while simultaneously relying on andreproducing the state as a safe, secure and ordered space in an anarchic and dis-ordered international realm. These constructions are reproduced through theregulation of human movement and healthcare by public and private entitiesthat operate in the spaces created by and through these practices.

8This list represents a comprehensive listing of all possible developments covered by the four corporationsunder examination for which one can purchase insurance.

173Scott Watson

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Documents

Back Home, Safe and Sound: The Public and Private Production of Insecurity