Innovation in Global Health Governance

Innovation in Global Health Governance

Global Environmental Governance Series Editors: John J. Kirton, Munk Centre for International Studies, Trinity College, Canada and Miranda Schreurs, Freie Universität Berlin, Germany Global Environmental Governance addresses the new generation of twenty-first century environmental problems and the challenges they pose for management and governance at the local, national, and global levels. Centred on the relationships among environmental change, economic forces, and political governance, the series explores the role of international institutions and instruments, national and sub-federal governments, private sector firms, scientists, and civil society, and provides a comprehensive body of progressive analyses on one of the world’s most contentious international issues. Recent titles in the series (full listing continued at the back of the book) Environmental Skepticism Ecology, Power and Public Life Peter J. Jacques ISBN 978-0-7546-7102-2 Transatlantic Environment and Energy Politics Comparative and International Perspectives Edited by Miranda A. Schreurs, Henrik Selin, and Stacy D. VanDeveer ISBN 978-0-7546-7597-6 The Legitimacy of International Regimes Helmut Breitmeier ISBN 978-0-7546-4411-8 Governing Agrobiodiversity Plant Genetics and Developing Countries Regine Andersen ISBN 978-0-7546-4741-6 The Social Construction of Climate Change Power, Knowledge, Norms, Discourses Edited by Mary E. Pettenger ISBN 978-0-7546-4802-4

Innovation in Global Health Governance Critical Cases

Edited by Andrew F. Cooper The Centre for International Governance Innovation, Canada JOHN J. KIRTON University of Toronto, Canada

© Andrew F. Cooper and John J. Kirton 2009 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise without the prior permission of the publisher. Andrew F. Cooper and John J. Kirton have asserted their right under the Copyright, Designs and Patents Act, 1988, to be identified as the editors of this work. Published by Ashgate Publishing Group Ashgate Publishing Company Wey Court East Suite 420 Union Road 101 Cherry Street Farnham Burlington, VT 05401-4405 Surrey GU9 7PT USA England Ashgate website: http://www.ashgate.com British Library Cataloguing in Publication Data Innovation in global health governance : critical cases. (Global environmental governance series) 1. World health 2. Communicable diseases - Prevention International cooperation I. Cooper, Andrew F. II. Kirton, John J. 362.1 Library of Congress Control Number: Cooper, Andrew Fenton, 1950Innovation in global health governance : critical cases / by Andrew F. Cooper and John J. Kirton. p. cm. Includes bibliographical references and index. ISBN 978-0-7546-4872-7 -- ISBN 978-0-7546-8985-0 (ebook) 1. World health. 2. Public health--International cooperation. I. Kirton, John J. II. Title. RA441.C665 2009 362.1--dc22 09ANSHT  ISBN 978 0 7546 4872 7 eISBN 978 0 7546 8985 0 (ebook)

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Contents List of Tables List of Figures List of Contributors Preface and Acknowledgements List of Abbreviations and Acronyms Part I Introduction 1 Critical Cases in Global Health Innovation Andrew F. Cooper, John J. Kirton, and Michael A. Stevenson

vii viii ix xi xv

3

Part II Responding to Pandemics: Severe Acute Respiratory Syndrome 2 Epidemic of Fear: SARS and the Political Economy of Contagion Andrew T. Price-Smith and Yanzhong Huang

23

3 Lessons from SARS: Past Practice, Future Innovation Carolyn Bennett

49

4 The WHO and SARS:The Challenge of Innovative Responses to Global Health Security Adam Kamradt-Scott

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Part III Preparing for Pandemics: Avian InflUenza 5 SARS and Avian Influenza in China and Canada: The Politics of Controlling Infectious Disease Sonny Shiu-Hing Lo

83

6

7

The Role of Civil Society in Pandemic Preparedness Kathryn White and Maria Banda

105

In-Flew-Enza: Pandemic Influenza and Its Security Implications Yanzhong Huang

129

Part IV Accessing Affordable Medicines 8 Coming to Terms with Southern Africa’s HIV/AIDS Epidemic Hany Besada

155

vi

9

Innovation in Global Health Governance

The Renovation of Institutions to Support Drug Access: Is it Enough? Jillian Clare Cohen-Kohler

10 Global Health Governance from Below: Access to AIDS Medicines, International Human Rights Law, and Social Movements Lisa Forman

179

193

Part V Conducting Campaigns against Chronic Illness: Polio and Tobacco 11 Rotary International and Eradicating Polio Robert Scott, Wilfrid Wilkinson, and John Eberhard 211 12 Globalisation and the Politics of Health Governance: The Framework Convention on Tobacco Control Jeff Collin and Kelley Lee

219

Part VI Defining Future Directions in Global Health Governance 13 Forging the Trade Link in Global Health Governance Benedikte Dal, Laura Sunderland, and Nick Drager

245

14 Explaining Compliance with G8 Health Commitments, 1996–2006 John J. Kirton, Nikolai Roudev, Laura Sunderland, and Catherine Kunz

257

15 Global Health Initiatives: A Healthy Governance Response? Caroline Khoubesserian

285

Part VII Conclusion 16 Innovation in Global Health Governance John J. Kirton and Andrew F. Cooper

309

Bibliography Index

341 381

List of Tables Table 5-1:

SARS and the Impact on Various Countries and Places, 1 November 2002 to 31 July 2003 Table 5-2: Infectious Disease Control, Regime Openness, and Size Table 5-3: Infectious Disease Response, Leadership Decisiveness, and Departmental Coordination Table 7-1: Estimates of the Economic Damage from Pandemic Influenza Table 7-2: Total Exports as Share of Gross Domestic Product and Estimated Economic Shocks Table 7-3: State Capacity, Civil Society Engagement, and Sociopolitical Impacts Table 8-1: Regional Comparison of HIV/AIDS, 2001 and 2007 Table 8-2: HIV/AIDS Indicators for South Africa Table 8-3: The Impact of HIV/AIDS on HIV-Related Health Services in Southern Africa Appendix 13-1: Implementing the Resolution on International Trade and Health Appendix 13-3: Diagnostic Tool for Trade and Health Appendix 14-1: An Overview of G8 Health Performance Appendix 14-2: G8 Health Compliance by Commitment and Country Appendix 14-3: G8 Health Compliance by Issue Area and Country Appendix 14-4: Compliance Catalysts Defined Appendix 14-5: G8 Health Commitments with Compliance Catalysts, 1996–2005 Appendix 14-6: Specific International Organisations and G8 Bodies, by Commitment Table 15-1: Global Health Initiatives with Annual Budgets Appendix 16-1: The Challenge-Response-Innovation Framework Appendix 16-2: Cases Appendix 16-3: International Institutions Involved in Global Health Governance Appendix 16-4: Instrumental Innovations in Global Health Governance Appendix 16-5: Institutional Innovations in Global Health Governance Appendix 16-6: National Innovations in Global Health Governance Appendix 16-7: Ideational Innovations in Global Health Governance

86 88 88 135 138 142 156 162 168 254 256 270 272 274 276 278 282 286 332 333 334 336 337 339 340

List of Figures Appendix 13-2: The House that GATS Built

255

List of Contributors Maria Banda is a JD candidate at Harvard Law School and a DPhil candidate at Oxford University, a Trudeau Scholar, and a Catherwood Scholar. Carolyn Bennett is a physician who served as Canada’s minister of state for public health from 2003 to 2006. Hany Besada is a senior researcher on weak and fragile states and leader of the Health and Social Governance program at The Centre for International Governance Innovation in Waterloo, Canada. Jillian Clare Cohen-Kohler is a professor at the Leslie Dan Faculty of Pharmacy and the lead researcher of the Initiative for Drug Equity and Access. Jeff Collin is a senior lecturer in global health policy at the Centre for International Public Health Policy at the University of Edinburgh. Andrew F. Cooper is the associate director of the Centre for International Governance Innovation and a professor in the Department of Political Science at the University of Waterloo. Benedikte Dal is a technical officer in the Department of Ethics, Equity, Trade, and Human Rights at the World Health Organization. John Eberhard is a past director of Rotary International, executive director of the Canadian Rotary Collaboration for International Development, chair of Disaster Relief—Rotarian Action Group, and past president of the Rotary Club of London, Ontario. Lisa Forman is a postdoctoral fellow with the Canadian Institutes of Health Research and the Comparative Program on Health and Society at the Munk Centre for International Studies at Trinity College in the University of Toronto. Yanzhong Huang is a professor and the director of the Center for Global Studies in the John C. Whitehead School of Diplomacy and International Relations at Seton Hall University. Adam Kamradt-Scott is a research fellow at the London School of Hygiene and Tropical Medicine.



Innovation in Global Health Governance

Caroline Khoubesserian works with the International Red Cross Society in Haiti. John J. Kirton is director of the G8 Research Group, director of the G20 Research Group, and a professor of political science at the Munk Centre for International Studies in Trinity College at the University of Toronto. Catherine Kunz holds a Master of Arts in Economics from McGill University. Kelley Lee is Reader in Global Health at the London School of Hygiene and Tropical Medicine. Sonny Shiu-Hing Lo is a professor of political science at the University of Waterloo. Andrew T. Price-Smith is director of the Project on Energy, Environment, and Security and a professor of political science and adjunct professor of environmental science at The Colorado College. Nikolai Roudev is a PhD candidate in political science at Stanford University. Robert S. Scott is former chair of the International PolioPlus and of the Rotary Foundation, and past vice-chair of Rotary International. Michael A. Stevenson is a PhD candidate at the University of Waterloo and a Balsillie Fellow at the Centre for International Governance Innovation. Laura Sunderland is the branch and membership coordinator at the Canadian International Council. Kathryn White is executive director of the United Nations Association of Canada. Wilfrid Wilkinson is past-president of the Rotary International, chair of Rotary’s ‘Reach Out to Africa’ committee, and the Rotary PolioPlus National Advocacy Advisor for Canada.

Preface and Acknowledgements This volume was inspired by the contemporary health crisis in the world and the manifest failure of the existing galaxy of global governance arrangements to cope. It takes as its central theme the need for innovation in the ideas and institutions of global health governance that have dominated for so long and still stand in centre place, but are now rapidly challenged, contested, and changing in response to new entrants in the field. This book continues the tradition in Ashgate Publishing’s Global Environmental Governance series of exploring the central issues and contemporary challenges of global governance in places where the stable single-issue areas of old are coming together in today’s more intensely integrated, interconnected world. Nowhere is this fusion greater than in the field of health. Here the environmental causes and consequences of health are quickly becoming more understood. The broader socioeconomic determinants and results of health are becoming a dominant paradigm in the health field. And the link between trade and health is moving to centre stage. Such interwoven issues now stand at the core of the global health policy agenda and thus of this book. But they and their components are still largely governed by the single-issue international organisations of old. Only a few integrative bodies—the United Nations, the G8, and new multi-stakeholder forums—are called upon to forge the needed connections and coherence in an effective way. That is why the need for innovation in global governance provides the focus for this work. To address the critical challenges, global governance responses, and patterns of innovation in ideas and institutions in the world of health, this volume brings together the resources of two scholarly research programmes. The first is that of the Centre for International Governance Innovation (CIGI) and the University of Waterloo, under the direction of John English and Andrew F. Cooper. The second is that of the research programmes on ‘Global Governance and the G8’ and ‘Strengthening Canada’s Environmental Community Through International Regime Reform’ (EnviReform), under the direction of John Kirton, and of the Centre for Global Health and International Affairs under the direction of John Kirton and James Orbinski, at the Munk Centre for International Studies at Trinity College in the University of Toronto. It builds on the previous volume Governing Global Health: Challenge, Response, Innovation, edited by Andrew Cooper, John Kirton, and Ted Schrecker, which deals with the contribution of the UN and G8 systems and of civil society organisations in coping with the contemporary health crisis. This current volume explores how these and other actors, with their old and new ideas, confront some of the critical cases of the major diseases and health shocks that afflict people throughout the world today.

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Acknowledgements In producing this volume, we have enjoyed the exceptional support of those who have contributed so much in so many different ways. We are grateful in the first instance to CIGI. It provided funding, organised and hosted the meetings and workshops, and ensured that this effort moved from the initial stage of research projects and papers into this polished, published book. CIGI also took the lead in bringing in the multistakeholder community, led by Rotary International, to enrich the effort. We are also grateful to Ted Schrecker at the Institute of Population Health at the University of Ottawa for his efforts in organising workshops and recruiting scholars and practitioners, including several from the developing world. We also owe much to the G8 Research Group, particularly to Ella Kokotsis, director of research, Jenilee Guebert, senior researcher, Madeline Koch, managing director, and the many hard-working and dedicated researchers who have contributed so much to this volume. We are also grateful to the Social Sciences and Humanities Research Council of Canada, under its strategic grant programme on ‘Social Cohesion in a Globalizing Age’, for its award to the University of Toronto’s EnviReform project and its standard research grant to John Kirton for his project on ‘After Anarchy: G8 Governance in a Globalizing World’. Institutionally, we appreciate the loyal support of our colleagues, administrators, and staff at our home institutions. At CIGI we appreciate very much the support of John English, the executive director, and Daniel Schwanen, acting executive director. Valuable work was also done by Andrew Schrumm, research officer, and Kelly Jackson, former research project manager, as well as Thomas Agar, research assistant. Michael A. Stevenson made a highly constructive contribution in the last stages of the project. As with all projects at CIGI, we are indebted to the strong support and personal interest of Jim Balsillie, chair of CIGI’s operational board of directors and co-CEO of Research in Motion. At the University of Waterloo our thanks go to Ken Coates, dean of arts, Bob Kerton, former dean of arts, and Amit Chakma, vice-president and provost. At the University of Toronto our gratitude goes to the Centre for International Studies at the Munk Centre for International Studies and its director, Louis Pauly. At the Centre for International Studies Tina Lagopoulos and her colleagues worked tirelessly in support of our work. We owe a particular word of thanks to Madeline Koch, for her editing and production skills and for her dedication in producing this book. We are particularly appreciative of the work by Peter I. Hajnal, who supervised the anonymous referee process of this manuscript. We are most grateful for the dedication, thoroughness, and insight of those referees, whose important comments have been taken fully into account. As always we reserve a special word of thanks for Kirstin Howgate and her colleagues at Ashgate for recognising the value of producing this volume and for working so effectively, and with such generous patience and understanding, to ensure the smooth adoption and ultimate publication of this book.

Preface and Acknowledgements

xiii

We thank our students for their endless enthusiasm, constructive criticism, intellectual contributions and challenges, and continuing commitment to the causes and issues dealt with in this book. We acknowledge, as always, the patience and support of our families as we laboured to organise our research, produce our own initial papers, and convert rough drafts into finished chapters. It is to our spouses, Sarah Maddocks and Mary Kirton, that we dedicate this work. Andrew F. Cooper and John J. Kirton January 2009

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List of Abbreviations and Acronyms ADB Asian Development Bank AIC Akaike information criteria AIDS acquired immune deficiency syndrome APEC Asia-Pacific Economic Cooperation ART antiretroviral therapy or treatment ASEAN Association of South East Asian Nations AU African Union AZT zidovudine BAT British American Tobacco BIT bilateral investment treaty BSE bovine spongiform encephalopathy CAC Codex Alimentarius Commission CAMR Canadian Access to Medicines Regime CBACI Chemical and Biological Arms Control Institute CDC U.S. Centers for Disease Control and Prevention CESCR United Nations Committee on Economic, Social, and Cultural Rights CFIA Canadian Food Inspection Agency CFR case fatality rate CIA United States Central Intelligence Agency CIDA Canadian International Development Agency CIGI The Centre for International Governance Innovation CIPIH Commission on Intellectual Property Rights, Innovation, and Public Health CME Canadian Manufacturers and Exporters China CDC China Center for Disease Control and Prevention CSIS Center for Strategic and International Studies CSR corporate social responsibility DALY disability-adjusted life year DFID Department for International Development (United Kingdom) ECOSOC Economic and Social Council (of the United Natios) EPI Expanded Programme on Immunization (of the World Health Organization) FAO Food and Agriculture Organization FCA Framework Convention Alliance FCO United Kingdom Foreign and Commonwealth Office FDI foreign direct investment FCTC Framework Convention on Tobacco Control FTA free trade agreement

xvi

G7

Innovation in Global Health Governance

Group of Seven (Canada, France, Germany, Italy, Japan, the United Kingdom, and the United States) G8 Group of Eight (G7 plus Russia) G20 Group of Twenty finance ministers and central bank governors (G8 plus Argentina, Australia, Brazil, China, India, Indonesia, Mexico, Saudi Arabia, South Korea, and Turkey) GATS General Agreement on Trade in Services GATT General Agreement on Tariffs and Trade GAVI Global Alliance for Vaccines and Immunisation GDP gross domestic product GHSAG Global Health Security Action Group GHSI Global Health Security Initiative GOARN Global Outbreak Alert and Response Network GPEI Global Polio Eradication Initiative GPHIN Global Public Health Intelligence Network HIV human immunodeficiency virus HKSAR Hong Kong Special Administrative Region HPAI highly pathogenic avian influenza IAVI International AIDS Vaccine Initiative ICJ International Court of Justice IDB Inter-American Development Bank IGWG Intergovernmental Working Group on Public Health, Innovation, and Intellectual Property (of the World Health Organization) IHR International Health Regulations (formerly known as the International Sanitary Regulations of 1903) IHR(2005) Revision of the International Health Regulations ILO International Labour Organization IMF International Monetary Fund INB intergovernmental negotiating body IO international organisation IOM Institute of Medicine of the National Academies IPR intellectual property right IPS International Policy Statement (of the Government of Canada) IPV inactivated polio vaccine ITGA International Tobacco Growers Association LDC least developed country LPAI low-pathogenic avian influenza MDG Millennium Development Goal MNC multinational corporation MSF Médecins Sans Frontières NACP National AIDS Coordination Programme (Zimbabwe) NAFTA North American Free Trade Organization NCE new chemical entity NGO nongovernmental organisation

Abbreviations and Acronyms

xvii

NID national immunisation day NPC National People’s Congress (of China) ODA official development assistance OECD Organisation for Economic Co-operation and Development OIC Organisation of the Islamic Conference OIE World Organisation for Animal Health OLS ordinary least squares OPV oral polio vaccine PAG Polio Advocacy Group PAHO Pan American Health Organization PE punctuated equilibrium PEPFAR United States President’s Emergency Plan for AIDS Relief PHAC Public Health Agency of Canada PRC People’s Republic of China PMA Pharmaceutical Manufacturers’ Association of South Africa PMTCT ��������������������������������������� preventing mother-to-child transmission PPP public–private partnership R&D research and development ROC Republic of China SAP structural adjustment programme SARS severe acute respiratory syndrome SPP Security and Prosperity Partnership of North America SPS Agreement Agreement on the Application of Sanitary and Phytosanitary Measures STB Stop TB Partnership TB tuberculosis TBT Agreement Agreement on Technical Barriers to Trade TFI Tobacco Free Initiative TRIPS Trade-Related Aspects of Intellectual Property Rights TSI Therapeutic Solidarity Initiative UNAIDS Joint United Nations Programme on HIV/AIDS UNAC United Nations Association of Canada UNCTAD United Nations Conference on Trade and Development UNDP United Nations Development Programme UNEP United Nations Environment Programme UNHCHR United Nations Office of the High Commission for Human Rights UNICEF United Nations International Children’s Fund UNSC United Nations Security Council USAID United States Agency for International Development USTR United States Trade Representative WFP World Food Programme WHA World Health Assembly WHO World Health Organization WTO World Trade Organization

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Part I Introduction

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Chapter 1

Critical Cases in Global Health Innovation Andrew F. Cooper, John J. Kirton, and Michael A. Stevenson

Global health is in a cascading crisis as the powerful process of globalisation gathers ever more of the world in its grip. Amidst the many material and epistemic advances brought by globalisation, many millions of people still die annually from infectious and chronic disease. These mega deaths are made all the more tragic, threatening, and morally reprehensible precisely because so many are predictable, preventable, and treatable now. For most of the past millennium, many died quickly, painfully, and prematurely from infectious diseases such as smallpox, plague, and cholera. They died in large part due to ignorance, malnutrition, poor water and sanitation, and the failure of the diagnosis and treatment process to protect their health. They were largely left with only divine retribution as the dominant cause of their illness and the provision of spiritual solace and the hope of a better afterlife when death approached. European imperialism carried new diseases and death to much of the world, while the growth of commerce and travel brought illness from ever more distant continents into the European core to exact a similarly fatal toll. Even with the growth of the national quarantine system over the past millennium, and the emergence of intergovernmental health conferences, regulations, and institutions and vast improvements in public hygiene and sanitation in the second half of the 19th century, many still died as the 20th century began. The great influenza pandemic at the end of World War I killed an estimated 50 million around the world, taking more lives than those killed deliberately during the world’s most deadly war to date (Soper 1919; Harrison 2006). The 20th century promised a much brighter and healthier future in so many ways. It brought advances in medicine, hygiene, education, sanitation, and public health. These came with the professionalisation of health practitioners, the creation of pharmaceutical firms of national and then international reach, and the advent of philanthropic nongovernmental organisations (NGOs), such as the Rockefeller Foundation, devoted to research to alleviate humanity’s suffering. At the end of World War II the victorious powers created the World Health Organization (WHO) to produce health for all and assist the new states freed from colonialisation as they constructed their governments to provide their citizens with better health (Goodman 1971). As with earlier imperial ventures and world wars, the Cold War and periodic hot wars that followed also spurred innovation, for the imperial powers acquired



Innovation in Global Health Governance

new national security needs to identify, treat, and prevent the diseases their troops encountered in the many exotic locations where they were now deployed. At the height of the Cold War, the success of the WHO-led smallpox eradication campaign demonstrated that ideological differences could be overcome in the name of global health. With the ensuing collapse of the Soviet Union and the spread of openness to regions of the globe where it had long been denied, there was great anticipation that chief among its fruits would be significant improvements in the health and welfare of citizens everywhere. Post–Cold War globalisation created a new generation of possibilities and resources to save lives, increase life expectancy, and improve the quality of human health and life. It brought and spread new knowledge, diagnostic techniques, therapeutic options, and medicines to treat some of the most important diseases. These were delivered by health professionals with ever more training and specialised knowledge and received by a more informed citizenry taking control of their own health and life. There emerged a greater awareness of the social, economic, environmental, and political determinants of health. The advent of low-cost and rapid communications and transportation promised to spread information, assistance, and wealth to foster health everywhere in the world. But globalisation also spread disease and death (Drager and Beaglehole 2001). The rapid increase in social and economic interconnectedness led to new health threats and the re-emergence of old health threats long thought to be under control. In the span of just over two decades, HIV/AIDS has gone from being unknown to science to being the single most important infectious disease in the world. In some countries it has prevalence rates so high that it has become a significant threat to economic and national security and, potentially, to national survival itself (PriceSmith 1999; Peterson 2002). While many now receive affordable treatment, even more become infected each year. Other diseases such as tuberculosis (TB) and vector-borne diseases such as dengue fever and malaria are re-emerging as major global health threats, with their control complicated by the development of resistance to many of the existing therapeutics agents used in their treatment (Osterholm 2005). Biological and political resistance to many of the proven medicines and treatments long relied on is, in many cases, on the increase. Globalisation increases the rate and means for health threats to be transplanted from one region of the world to another. At the same time, globalisation has enabled healthcare professionals badly needed in their own poor countries to migrate to better jobs and opportunities in the already abundantly endowed North. It has further facilitated the export and marketing of behaviour and lifestyle choices associated with adverse health effects. This has given rise to new epidemics of conditions and chronic diseases associated with alcohol, smoking, and consumption of processed foods, such as diabetes, obesity, and various cancers, as well as a range of diseases associated with exposure to a long list of environments pollutants (Beaglehole and Yach 2003). This comes at a time when governments around the world have been forced by persistent poverty, financial crisis, natural disaster, and war to watch their public health systems decline and the economic and health inequalities among their citizens rise (Garrett 1996).

Critical Cases in Global Health Innovation



The Inadequate Governance Response In the face of such demanding deadly challenges—now reaching crisis proportions in the sheer volume of avoidable deaths—the global community still struggles to devise an appropriate and adequate response. The causes and cures of the compounding global health crisis that come from agriculture, demography, economics, ecology, security, and technology are well known, but seldom related to health and a health governance response in a comprehensive or coherent way. Through its general requirements for reductions in public sector spending, the neo-liberal economic policies espoused by the International Monetary Fund (IMF) and the World Bank have often counterproductively constrained the national governments that borrow from them and thus made them fail to protect global health (Thomas and Weber 2004). Lack of capacity and an abundance of corruption hamper national governments around the world. Within wealthy countries, there still exists an isolationist mentality that views the developing South as a reservoir of human disease that can be guarded against by better medicines, bigger border barriers, and more protective policies at home (Aginam 2004). Yet domestic health policy cannot address the determinants of health that originate beyond national borders. And the dire poverty in much of the developing world is still found in abundance inside the developed North itself (Kickbusch and de Leeuw 1999). Sovereignty, national suspicions, and profit motives compound the challenge. Attempts to harmonise national policies for the purpose of strengthening global health continue to face fierce resistance from states unwilling to give up sovereignty, as shown by the recent process of revising the International Health Regulations (IHR) (Gostin 2004). Hindered by conflict over human rights, bioterrorism, and the political status of Taiwan, the success of those regulations depends ultimately on whether states decide to implement them (Fidler and Gostin 2006). Certainly much of the responsibility can be laid on the doorstep of national governments, as states have yet to internalise the value of public health as a human right (Fidler 2001). But other actors share the blame. Transnational pharmaceutical companies have had little financial incentive to invest in the research and development (R&D) of drugs for neglected diseases such as trypanosomiasis, even though the moral imperative has always been there (Trouiller et al. 2002; t’Hoen 2002). At the centre of the growing array of actors responsible for governing global health stands the WHO. This organisation, charged with improving the health of the world’s population, has been limited by political and financial constraints imposed by its member states. It may indeed need radical reform to do its job in today’s world (Godlee 1994). There is a gap between monies committed and what is actually delivered (Labonté and Schrecker 2004). However, the principal impediment to improving global health is not merely lack of money but the poorly coordinated and bureaucratic nature of the disbursement of funds. It is also the tendency of governments, international organisations, and public-private partnerships (PPPs) to focus on individual diseases instead of vigorously investing in health human resources and public health infrastructure and working to reduce social, economic,



Innovation in Global Health Governance

and environmental determinants of disease in both the developing South and in the developed North (Garrett 2007). The comprehensiveness, coherence, and credibility of global health governance are ultimately at stake.

Recent Innovations In light of these growing health challenges and failures in the governance response, there has been considerable innovation, especially as many new actors have gotten into the global health governance game (Cooper 2007). In the realm of institutions, PPPs have demonstrated their value in areas where the public sector lacks skills and resources, such as product development, manufacturing, and marketing, even if PPPs are not appropriate for policy development or regulation itself (Widdus 2001). In the realm of ideas, the concept of global public goods has arisen as an effective way to raise money for mechanisms to strengthen communicable disease control (Smith et al. 2004). The proposal to develop a global health research fund through direct public investment in vaccine development, as well as an international health treaty to enshrine countries’ commitments for such a fund, has been widely embraced, showing that new international norms are being developed regarding the concept of global health (Archibugi and Bizzarri 2004). Investing in public health is increasingly perceived to be a core criterion of ‘good governance’ (Dodgson, Lee, and Drager 2002; Fidler 2004). Philanthropists led by Bill and Melinda Gates and faith-based communities, private sector corporations, and celebrities from the arts, athletics, and entertainment have come forward to mobilise much more money, awareness, expertise, and political pressure than before. And because of the intersection of domestic and foreign policy, consensus is mounting toward pooling state sovereignty and organising global health governance through a series of intergovernmental networks, with an unencumbered WHO coordinating global health policy (Kickbusch 2000; Taylor 2004). Indeed, there is a cornucopia of innovative individuals, institutions, ideas, and instruments now engaged and available. The central challenge for global public health is not only to add more, but above all to determine in disciplined fashion which ones work under different circumstances to generate the heath all deserve.

The Analytical Framework This book takes up that task. Its first and central purpose is to develop and test in critical cases an analytical framework that explains the process of innovatively delivering global public health in today’s complex, rapidly changing, globalised world. Its second purpose is to assess on this basis the current state of innovation in global health governance. Its third purpose is to evaluate and expand the innovations that could improve the way the governance system works and the health that results. This volume builds directly on a general framework of global health governance first constructed to assess and improve the performance of the major intergovernmental

Critical Cases in Global Health Innovation



institutions of the United Nations and the G8 and the many actors now involved in their governance systems (Cooper, Kirton, and Schrecker 2007). That framework flowed from the literature in the rapidly emerging field of global health governance (Kirton 2009, forthcoming). The framework had three core components: physical challenges to health, governance responses to these challenges, and the innovation called forth and needed in the face of new challenges when the old responses failed. That general framework of challenge-response-innovation conceived of intergovernmental institutions, national governments, civil society organisations, private firms, and individual citizens as complacent reactors, constrained learners, and reluctant innovators. Only seldom were they prescient, creative, proactive, strategic actors who regularly and accurately anticipated future trends and adapted to or prevented the threats to health that physical challenges brought. To be sure, there were some supply-driven successes, such as the eradication of smallpox. But mostly the principal actors’ innovations were reactions to severe crises and shocks. Their next response to such crises typically entailed trying to do more of the same, on the basis of their existing missions, mandates, organisational routines, professional repertoires, and resources, based upon the dominant understanding of cause-andeffect relationships to solve the new problem. The initial instinct was to replicate past successes in new cases. The first defence in the face of failure was to plead for more money and other resources to solve the current challenge. Yet in response to the failure of these old actors and approaches to meet those challenges, there arose competition from the many new actors and new approaches that had entered the global health game. From this challenge and failure of the old responses and new competition came innovation in the dominant institutions and ideas that govern global health. Driving successive stages of this challenge-response-innovation dynamic is the process of globalisation, as it has intensified from the mid-19th century until now. Most broadly, globalisation has increased the scale, speed, scope, simultaneity, and domestic intrusiveness of disease and the other forces that directly or indirectly harm human health. This has placed the demand for global health governance on centre stage in many countries as the 21st century unfolds. Globalisation has also intensified the economic, ecological and social interconnectedness, interdependence, complexity, and uncertainty that add force to contemporary global health challenges. Yet the scientific and information revolutions fuelled by globalisation have also brought new insights and resources through which many more actors can respond to the challenge in innovative and effective ways. The challenge-response-innovation framework developed and tested in this book builds on this basic conception. It proceeds on three levels. The first traces the process and pathways of action in each of the three components of challenge, response, and innovation. The second causally connects these three components by identifying the responsiveness, appropriateness, and effectiveness with which challenges evoke response and innovation. The third charts the overall transformation brought about by new non-state controlled vulnerabilities, by governance innovativeness as a self-



Innovation in Global Health Governance

sustaining, spreading process, and by non-Westphalian forms of sovereignty as the innovative key. The first level of process charts in detail the pathways of challenge, response, and innovation by identifying in each case who does what to whom, to what effect, and why. This charting starts with the problem of the physical health challenges that could catalyse a public governance response from various players and that could lead to innovation on their part. Such physical health challenges, with their ultimate origins in human, animal, and plant biology or material chemistry, can be brought by state, non-state, and non-human actors or a mixture of the above. They can be intentional, targeted, and guided or unintentional, random, and uncontrolled. They can emerge and remain in the developed North or developing South, or move from South to North or North to South. They can arise and spread, through physical and psychological processes, in a slow, incremental, largely invisible fashion, or in a sudden, severe, concentrated, visible, shocking, panic-inducing one. The second component—public governance response—involves a similar tracing. Such responses can come from some or all of concerned and caring individuals, health professionals, private sector, civil society actors, nation-states, and international institutions. They can respond consciously to the physical health problem or unknowingly in ways that affect the challenge for better or worse. They can respond at the source, at the borders the threatening challenge crosses, or at the destinations to which it flows. The third component of innovation follows a similar cadence. It conceives of innovation broadly as changes over time that are novel or a rediscovery of past concepts or practices, rather than a return to what has been regularly relied on before. It asks who innovates, with the spectrum ranging from individuals to international institutions themselves. It traces how deliberately they innovate, from accidental discoveries through trial and error to purposeful big project science. And it identifies where they innovate, with the possibilities ranging from the physical source to the destination to which the disease has spread. The second level of system responsiveness causally connects the three components of challenge, response, and innovation. It does so by identifying the relationships among them according to the three criteria of responsiveness, appropriateness, and effectiveness. Responsiveness refers to the speed with which the first appearance of a physical health challenge affecting a large population evokes a response and then innovation as a result. Here the spectrum extends widely from non-existent or slow, through immediate responses and resulting innovations in the middle, to proactive, preventive action at the other end of the scale. For convenience the framework is arranged with the physical challenge as the independent variable, public governance response as the intervening variable, and governance innovation as the dependent variable. But through feedback loops and autonomously, innovation can start new processes of public governance that prevent physical challenges before they start. The criterion of appropriateness refers to the fit between the physical problem, governance response, and resulting innovation in its diagnosis, resource mobilisation, targeting, instrumentalities, and centre of responsibility. The criterion of effectiveness

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refer to the quality of the response and innovation in terms of the number of lives saved and improved and the broader ecological, social, economic, and politicalsecurity values enhanced. The third level of system transformation assesses the causal connections according to three criteria. The first is the new vulnerability, in which non-state and nonhuman actors create in unconscious, unintended, untargeted, uncontrolled fashion the physical health challenges that rapidly and readily flow across state borders around the world to overwhelm the inherited governance responses and kill or harm many there (Kirton 1993). This ‘neo-vulnerability’ is different from the inherited, largely Westphalian structure in which states and their national governments largely cause or control disease within or at their borders and rely on sovereignty-respecting international diplomacy, agreements, or institutions for whatever international coordination is required to cope. The old vulnerability arose in a still state-centric world of bioweapons and biowarfare: states sent controlled threats against their adversaries in ways that the latter’s unilateral change in national policy could not protect against and where such failure bred new international institutions to cope (Keohane and Nye 1977). Neo-vulnerability, in contrast, arises in an era of intense globalisation where many threats from many unconscious, uncaring sources attack and overwhelm the standard repertoire of national and intergovernmental policy responses and call for multiple sources and forms of innovation within multilevel governance instead. Here the size, speed, and spread of the new vulnerability is hypothesised to catalyse multi-actor innovation when the initial response from Westphalian governance fails. The second criterion is innovativeness. It refers first to the speed with which an innovation effectively solves the challenge when the previous Westphalian governance repertoire has not. It also refers to the spread of the innovation in a broader process of borrowing and adaptation that saves lives in other places, assaulted by other diseases, in coming years. Here the novel, appropriate, and effective innovation created in response to a particular health challenge becomes institutionalised, adopted by other actors for other purposes, and ultimately inspires a culture of innovation overall (Homer-Dixon 2001). The third criterion is the new sovereignty. It arises as actors beyond nation-states and their intergovernmental institutions emerge as appropriate and effective centres of innovation and thus become legitimately embedded as authoritative institutions of global health governance. In the realm of ideas, health governance passes from being a matter of national security for imperialism, war, or counter-terrorism, or a matter of economic advantage in a relative capability competition or a matter of redistribution to develop countries than can help or harm; it becomes a right and a responsibility to protect human lives and the global ecosystem on which all life depends. In the realm of institutions, those actors that can appropriately, effectively, and legitimately work with others to produce such values create the fluid networks that are the health sovereigns of the new age. This new sovereignty transcends the new, ‘open source’ anarchy that the entry of so many more diverse players into global health politics, diplomacy, and governance has brought (Fidler 2007, 2008).

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The Analytical Strategy To develop and test this framework this book looks beyond and below the major intergovernmental institutions long responsible for global health. It starts with specific, current, critical cases of disease that provide the catalyst for the cadence of challenge-response-innovation to start. Five cases provide the focus: severe acute respiratory syndrome (SARS), avian influenza, HIV/AIDS, polio, and tobacco. These cases provide the necessary variation on the independent variable of physical challenge. SARS arose from non-human sources and spread in uncontrolled fashion with great speed from South to North. Avian influenza in its deadly human H5N1 form likewise arose from non-human sources and has spread in uncontrolled fashion, although more slowly and still largely where it started among countries of the developing South. HIV/AIDS emerged from non-human sources in the South but was spread by humans to and in the North and has slowly spread back across the South. Polio came from non-human sources and spread slowly across the North and South but has been driven back over many decades to a few remaining enclaves in the South. And tobacco flowed from intentional and conscious human activity first in the South, then largely in the North, and now increasingly in the South. Across these five cases, the physical character of the challenge alone does not readily account for the deaths these diseases have brought. The death toll from SARS and avian influenza has been modest, while that from the others has been very high. It is thus the quality of the governance response and the innovation that critically determines who lives and dies. To be sure, these five cases are by no means all of the many high-profile and neglected, acute, and attrition cases of communicable and non-communicable diseases that deserve attention by global health scholars and practitioners today. Indeed, in focussing on these big five, this volume deals with a wide number of others that are and should be on the global health agenda today. These five allow for a point of entry to this much broader terrain, and a disciplined, detailed way of identifying lessons that could be used much more broadly to understand and improve global health as a whole. To explore the dynamics of challenge-response-innovation, this book examines in turn these five cases along a spectrum from acute outbreak to diffuse attrition events. The individual sections devoted to the first three contain chapters that generally concentrate in turn on the challenge, response, and innovation. Each section and chapter deliberately contains some overlap in case subject and analytical components in order to facilitate and highlight comparison, convergence, and cumulation in the overall story of innovation in global health governance as a whole. To conduct this analysis, this book adopts a broad but bounded definition of the core, rapidly changing and heavily contested conceptions that comprise the scholarly field of global health. ‘Global’ refers to the geographic reach across many, substantially separated sovereign state boundaries of processes that directly do or could constitute, cause, cure, or otherwise change human health. ‘Health’, consistent with the definition contained in the WHO’s (1986) charter, consists of all physical

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and mental things that directly constitute and improve the longevity and quality of human life. ‘Governance’ is the conscious creating, shaping, steering, strengthening, and using of international and transnational institutions and regimes of principles, norms, rules, and decision-making procedures that influence how autonomous actors behave (Krasner 1983). ‘Diplomacy’, both generically and in the form of global health diplomacy, is the conscious practice of actors operating across international boundaries to get what they want from outsiders without the use of violent physical force. Scholars of international politics of realist, liberal-institutionalist, political economy, and constructivist traditions each have competing conceptions of how governance and diplomacy affect outcomes. But all agree on their importance, with classic realists highlighting diplomacy as the ultimate determinant of what happens in the world (Morgenthau 1948).

The Authors To enrich and apply this framework, this volume assembles the contributions of leading scholars, researchers, and practitioners from a wide array of global regions, scientific disciplines, and professional fields. It includes those from North America, Europe, Africa, and Asia, and those with extensive experience elsewhere in the developing world. The contributors work in major multilateral organisations, national governments, universities, research institutions, and civil society organisations. Their contributions come from the disciplines of political science, economics, law, sociology, medicine, pharmacy, and a wide range of component fields. The contributions draw upon a broad array of the major theories of global governance, including realism, liberal institutionalism, constructivism, epistemic communities, principal-agency theory, and complexity theory. This book’s purpose is not to test these competing theories against the evidence to identify and proclaim a winner, but to mobilise the insights of several traditions in an improved synthetic understanding of how global health governance does, could, and should work in the contemporary world. Thus many of the contributions are explicitly normative in inspiration, flow from positive analysis into policy-oriented judgements, and offer recommendations for further innovation of both practical and more visionary kinds.

The Authors’ Arguments Part II, ‘Responding to Pandemics: Severe Acute Respiratory Syndrome’, begins with the lessons from SARS, as the most dramatic and deadly of the infectious diseases recently assaulting the developed North from the developing South with striking severity, speed, and surprise. In Chapter 2, ‘Epidemic of Fear: SARS and the Political Economy of Contagion’, Andrew Price-Smith and Yanzhong Huang illustrate, through the case of SARS, how in a globalised world no country is immune to the potentially damaging economic

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effects of public health emergencies. They argue that SARS exposed the vulnerability of existing governance structures, and that the great fear generated by the failure of governments to control the disease had significant ramifications for the domestic economies of affected states. These proved to be a catalyst for structural change. The Chinese and Canadian experiences show how fear prompted large-scale population flight, avoidance of public spaces and significant decreases in consumer spending and investor confidence. Combined with an increase in healthcare delivery costs, this took a heavy economic toll on both countries. The significant economic impacts and the intense negative international scrutiny of government failings increased the prominence of public health issues among political elites. They created transparency and incentives for more proactive approaches to dealing with other pressing public health issues. The case shows that states need to be more proactive in preparing for unforeseen public health emergencies. SARS has led to significant macro-level innovations at the domestic level in affected countries, most notably in China, as well as to strengthening regional cooperation on public health in southeast Asia. However, it has not had a significant impact on global health governance. It did highlight the antiquated nature of the IHR reporting model and temporarily increased the power of the WHO. But it has not increased states’ compliance with international health regimes or the WHO’s long-term influence. In Chapter 3, ‘Lessons from SARS: Past Practice, Future Innovation’, Carolyn Bennett emphasises knowledge improvement and dissemination, collaboration, and leadership in improving global health outcomes. While SARS highlighted many areas of structural weakness, most notably how governments communicated with each other and with citizens, some jurisdictions performed admirably. Singapore designated one hospital to treat cases, performed contact tracing within 24 hours of case admission, held regular news briefings to share facts and uncertainties, and provided advice to citizens on how to protect themselves from infection. It thus offers a model for emulation and adaptation elsewhere. In Canada SARS led to learning and innovation through the creation of a fact-finding mission, the results of which generated the political will to create the Public Health Agency of Canada (PHAC) and the position of chief medical officer of health at the federal level. But governments must re-learn what public health means. There is merit in community-based ‘bottomup’ initiatives, such as Thailand’s community health liaisons. NGOs need to be included in public health planning and more emphasis must be placed on addressing the social determinants of health. Finally, there is a need for government candour on public health issues, requiring a shift in culture to be able to admit challenges and ask for help from the international community through the WHO. Effective global health governance requires fostering relationships based on respect and trust and a model of transparency and equity, evidence-based policy, and citizen engagement. In Chapter 4, ‘The WHO and SARS: The Challenge of Innovative Responses to Global Health Security’, Adam Kamradt-Scott examines the role and authority of the WHO during the SARS crises. He responds to positions taken by David Fidler, Andrew Cortell, and Susan Peterson that the WHO was guilty of ‘agency slack’, exceeding its authority and mandate and engaging in unauthorised, unprecedented,

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and undesired actions. Kamradt-Scott argues that the WHO was intended to be an independent entity, performing duties on behalf of member states. Communicable disease control was its primary purpose from its inception. The WHO’s response to SARS stood in stark contrast to its usual state-centric deferential approach to public health emergencies. While SARS was an exceptional epidemiological event, the WHO’s actions were entirely consistent with its mandate and explicitly authorised by the collective WHO membership through its approval of the WHO constitution. It directs the WHO to be the designated leader, coordinator, and policy formulator of global initiatives to control infectious disease. Several provisions within article 2 of the WHO’s (2006) constitution are explicit about this. The organisation’s interventionist approach, most apparent in its public criticism of the Chinese government, was sanctioned by member states through the formation of the Global Outbreak Alert and Response Network (GOARN) in 2000 and the passing of resolution WHA54.14 on Global Health Security: Epidemic Alert and Response in 2001 (WHO 2001). The ongoing revision of the IHR—the only treaty designed to combat the international spread of infectious diseases—gave the WHO discretionary powers regarding infectious disease policy and procedures. The WHO’s actions were thus in keeping with the expectations of the member states—that of an impartial technical organisation charged with a duty of care to safeguard the health of the global population. Part III, ‘Preparing for Pandemics: Avian Influenza’, presents a different set of challenges. In Chapter 5, ‘SARS and Avian Influenza in China and Canada: The Politics of Controlling Infectious Disease’, Sonny Shiu-Hing Lo argues that in today’s globalised world, where highly virulent pathogens can be rapidly transplanted anywhere and lead to unforeseen epidemics, a critical measure of state strength in health governance rests on its ability to cope with rapidly emerging public health crises. Three key performance measures—preparedness, transparency, and responsiveness—should be used to assess state capacity in this regard. In the Asian epidemics of acute, highly virulent respiratory infections such as SARS and H5N1 avian influenza, certain Asian jurisdictions, especially densely populated urban centres, both innovated successfully and failed. Other countries, such as Canada, can learn from these experiences to prepare for future public health emergencies such as a global influenza pandemic. Despite Toronto’s experience with SARS and the government’s development of the Pandemic Influenza Plan for the Health Sector, the Canadian public remains psychologically ill prepared for a large-scale public health emergency. Canada should instil a ‘crisis consciousness’, for example by ensuring Canadians are aware of the need of government to balance civil liberties with the need to maintain public safety, and prepare for a rapid mobilisation of civic resources to what will likely be an overextended healthcare workforce. It remains unclear whether the logistical challenges that plagued municipal, provincial, and federal governmental responses to SARS—specifically regarding roles, responsibilities, and communication—have been resolved. Lo thus proposes a 20-point action plan to bolster Canadian preparedness for dealing with the eventual epidemic attributed to a highly virulent and infectious pathogen.

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In Chapter 6, ‘The Role of Civil Society in Pandemic Preparedness’, Kathryn White and Maria Banda examine the challenge of avian influenza and what response is needed for society to be prepared for a global outbreak. They discuss how the inclusion of multiple levels and areas of society can benefit the planning for and the prevention of a pandemic. Beginning with the evolution of avian influenza, and the possible lessons learned from each of the responses seen thus far, they look at past failures and potential successes of the global health system and the possible role civil society can play. Turning to governance, they suggest that numerous actors are needed from a wide range of areas, including health, agriculture, trade, the environment, development, and civil society. The best approaches to controlling infectious disease are both transnational and multi-actor. Avian influenza requires a four-part response: a genuine commitment to human development, a dependable and all encompassing human rights system, a public security framework to deal with the security threats of ill health, and a new attitude toward environmental responsibilities that takes food security more seriously. Only when an all-encompassing plan is in place will an investment in global health governance be truly entrenched and society adequately prepared for a pandemic, whether it be avian influenza or some other infectious disease. In Chapter 7, ‘In-Flew-Enza: Pandemic Influenza and Its Security Implications’, Yanzhong Huang examines the potential implications of a virulent influenza pandemic on the international economy, on sociopolitical stability within states, and on regional security. He offers recommendations aimed at mitigating the identified risks. The world has changed since the last virulent influenza pandemic in 1918. Improvements have come from the increased prominence of public health within the political arena, the many advances in health sciences and care delivery, the vast improvements in communications technology, the multilayered network of non-state actors involved in health promotion and health care, and the existence of the WHO with a well-defined mandate to provide leadership during public health emergencies. However, 4 billion additional prospective human hosts in a world where access to health resources disproportionately favours populations in wealthy countries, where significantly higher levels of the population live in impoverished settings, where incentives to suppress information in certain jurisdictions remain strong, and where both people and goods cross borders at unprecedented rates may erode any advantage for population health. A future influenza pandemic may well be very damaging to the international economy, especially if its epidemiology resembles the pandemic of 1918. The SARS case suggests that how governments respond to a pandemic can greatly affect social and political stability. International security could be compromised if peacekeeping operations are interrupted or if governments resort to deliberately stoking sectarian tensions to detract from state failures. Governments should thus increase public health expenditures, increase capacity in developing countries through monetary aid as well as knowledge and technology transfer, strengthen national healthcare surge capacity while balancing influenza preparedness investments with other important infectious disease programmes, and improve risk communication skills and ties with civil society groups.

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Part IV, ‘Accessing Affordable Medicines’, takes up the issue of HIV/AIDS and the governance and human rights aspects of accessible medicine. In Chapter 8, ‘Coming to Terms with Southern Africa’s HIV/AIDS Epidemic’, Hany Besada examines the demographic and economic impacts of HIV/AIDS in Swaziland, Botswana, Zambia, Zimbabwe, and South Africa. These countries have some of the highest HIV/AIDS prevalence and associated mortality rates in the world. However, their governments have largely failed to reduce social determinants of disease transmission and increase access to antiretroviral treatment (ART) for those infected. Besada reviews individual governmental policy responses to the HIV/AIDS crisis, with a primary focus on South Africa, where HIV/AIDS-related mortality is likely to continue to increase. South Africa shows how inconsistent political leadership can be a major impediment to disease control. The most prominent indicator of poor domestic health governance is the consistently low percentage of individuals living with HIV receiving ART, despite concessions by large pharmaceutical companies that have allowed the country to manufacture low-cost generics domestically. There is also a government failure to reduce the social stigma associated with HIV infection. Yet there have been positive developments, such as the decisions of large firms to absorb the cost of ART for HIVpositive employees and a national HIV/AIDS policy emphasising prevention. While governments should re-evaluate what strategies have worked in the regional context, the international community must increase its financial aid to southern African states to subsidise the rising cost of treatment resulting from increased access to ART. It must also accept some responsibility for the migration of healthcare workers from southern African states to wealthier countries and offer some solutions. In Chapter 9, ‘The Renovation of Institutions to Support Drug Access’, Jillian Clare Cohen-Kohler asks how governments can maximise conditions for positive health outcomes at the same time as economic growth is supported through trade and incentives for the private sector, such as through the application of rigorous intellectual property law regimes. She argues that the potential tension between these objectives arises in the pharmaceutical sector. In a world that has distorted drug access and where one third of the population lacks regular access to medicines, there is a morally compelling reason to identify potential institutional obstacles to drugs irrespective of the potential commercial or budgetary costs. Governments should not experience any conflicting pressure when they design policies to improve drug access. Access to medicines should be viewed as a fundamental human right as expressed in international human rights law that places attendant obligations on states to ensure drug access. Article 12 of the UN’s International Covenant on Economic, Social, and Cultural Rights outlines the ‘right to the highest attainable standard of health’, which includes the right to the availability of essential medicines as defined by the WHO. In Chapter 10, ‘Global Health Governance from Below: Access to AIDS Medicines, International Human Rights Law and Social Movements’, Lisa Forman explores the actual power of the human right to medicines to enable access to ART for millions of people with HIV and AIDS throughout the world. She argues that the right to health in international law holds a transformative potential to overcome the political and

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economic obstacles to access posed by the Agreement on Trade-Related Aspects of Intellectual Property (TRIPS) set out by the World Trade Organization (WTO), the contestation of price reductions by multinational pharmaceutical companies and their host governments, and governments’ denial of AIDS medicines. In South Africa primary human rights battles over AIDS medicines show the contingent legal, social, and political variables that can determine the efficacy of this right. Using international legal compliance theories that debate whether actors comply with norms because they are coerced or persuaded into doing so, Forman suggests that the persuasive power of this right derives from its normative status in international law, amplified by rights discourse, advocacy, social mobilisation, and the devastating consequences of HIV/AIDS. However, rights-related persuasion is less effective and public coercion is necessary where powerful actors have entrenched economic or political interests. While litigation is a traditionally coercive legal tool, public pressure and moral shaming can be similarly coercive. When actors can maximise both the coercive and persuasive force of the right to medicines, they may be able to overcome legal and political obstacles to access. Part V, ‘Conducting Campaigns against Chronic Illness: Polio and Tobacco’, begins with Chapter 11 on ‘Rotary International and Eradicating Polio’. Robert Scott, Wilfrid Wilkinson, and John Eberhard use Rotary International’s longstanding global polio eradication efforts to illustrate how community service organisations can be major agents of change. The global polio eradication movement began in the 1950s with the development of two safe, effective, inexpensive vaccines. Since then great strides have been made through a collaborative effort involving multiple actors from several disciplines. The global eradication of a dreaded childhood disease now appears within reach. Rotary International, a large network of community service organisations composed of business and professional leaders from various backgrounds, has managed successfully to keep polio eradication on the agenda of governments for more than 20 years. Rotary’s PolioPlus programme, established in 1985, has raised hundreds of millions of dollars to fund immunisation campaigns in 125 countries and mobilised more than 1 million volunteers. Rotary has successfully partnered with governments, UN agencies, and multilateral organisations. Through networking and its capacity to cooperate, it has kept political apathy at bay and kept the issue of polio on the agendas of individuals who have the ability to influence outcomes. In Chapter 12, ‘Globalisation and the Politics of Health Governance: The Framework Convention on Tobacco Control’, Jeff Collin and Kelly Lee focus on the Framework Convention on Tobacco Control (FCTC), the WHO’s first attempt to exercise its authority to negotiate an international public health treaty. While the final text of the convention provides a more impressive policy template than many health advocates had expected, the significance of the FCTC lies primarily in the process of its negotiation. The chapter examines the political dynamics of the FCTC, highlighting the leadership role of developing countries, support among international organisations, a partial opening to civil society, and the efforts of tobacco companies to influence the process. The FCTC constitutes an explicit response to globalisation

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and an implicit attempt to regulate the conduct of transnational corporations. It thus has broader implications for global health governance. Part VI, ‘Defining Future Directions in Global Health Governance,’ turns from case studies to the general issue of governance. In Chapter 13, ‘Forging the Trade Link in Global Health Governance’, Benedikte Dal, Laura Sunderland, and Nick Drager argue that to effectively manage health risks that spill into and out of national borders, domestic health planners must work in tandem with their counterparts in foreign affairs and trade to attain policy convergence. Only through international cooperation and collective action can governments seek to address the multiple and inherently complex public health risks in an increasingly globalised world. As international trade is a major amplifier of public health risks across borders, states must develop robust population health policies prior to their integration into trade organisations and agreements. Responses to global health challenges increasingly require expertise in several disciplines. Multiple actors with often competing interests must be persuaded to reconcile their differences so that effective policies designed to mitigate health risks may be developed. Thus the emerging new discipline of health diplomacy is urgently in need of development. The concept and processes of health diplomacy are illustrated by the Intergovernmental Working Group on Public Health, Innovation, and Intellectual Property (IGWG), a body formed in 2007 to facilitate the work of the WHO’s Commission on Intellectual Property Rights, Innovation, and Public Health (CIPIH). The IGWG is an example of how evidencebased trade and health policy convergence can be attained through an inclusive and cooperative process, based upon the principles of trust and transparency, and the inclusion of performance measures to permit ongoing evaluation. In Chapter 14 ‘Explaining Compliance with G8 Health Commitments, 1996–2006’, John Kirton, Nikolai Roudev, Laura Sunderland, and Catherine Kunz examine why plurilateral and informal soft law bodies such as the G8 increasingly work with traditional international organisations to advance pressing international health issues. Beginning in the 1980s the G8 began to involve itself in health issues because of the growing vulnerability of its members states to emerging and reemerging infectious diseases, and a shared perception that the WHO was an ineffective leader in addressing global health challenges. The authors outline several schools of thought on the role of the G8 in strengthening global health governance, explain why G8 members comply with their respective health commitments, and identify how G8 leaders can craft their commitments in ways that improve compliance, by setting a one-year timetable and involving the WHO. In Chapter 15, ‘Global Health Initiatives: A Healthy Governance Response?’ Caroline Khoubessarian argues that official development assistance shortfalls and an under-funded WHO are the primary drivers of global health initiatives, such as funds set up through international organisations or large private foundations that typically focus on the prevention, control, or eradication of specific diseases. The successes of initiatives such as the International Campaign to Ban Landmines and the Jubilee Debt Campaign demonstrate that broad coalitions working outside of the traditional system can bring about positive change. Khoubessarian identifies

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the strengths and weaknesses of global health initiatives as a means of addressing global health problems. These initiatives have proven to be one way of building and engaging broad multi-layered networks. They may develop into effective global health governance if states are willing to support them through sustained funding. However, global health initiatives place specific single-issue initiatives in competition with one another for funding and attention, and mirror governments’ fixation on crisis management as opposed to developing collaborative, long-term public health strategies. These concerns need to be addressed before such initiatives can be viewed as global health governance structures worthy of emulation. Part VII concludes with Chapter 16, ‘Innovation in Global Health Governance’, by John Kirton and Andrew Cooper. It draws out patterns from the preceding 14 chapters. It begins with the challenges brought by globalised health threats and then examines the responses of the various public actors now involved in global health. It explores the innovations that have arisen in these responses to the new challenges. It concludes by assessing the responsiveness of the current system of global health governance and its possible transformation into a post-Westphalian form.

References Aginam, Obijifor (2004). ‘Salvaging Our Global Neighbourhood: Critical Reflections on the G8 Summit and Global Health Governance in an Interdependent World.’ Law, Social Justice, and Global Development, vol. 1. <www2.warwick.ac.uk/fac/soc/law/elj/lgd/2004_1/ aginam> (September 2008). Archibugi, Daniele and Kim Bizzarri (2004). ‘The Global Governance of Communicable Diseases: The Case for Vaccine R&D.’ Law and Society, vol. 27, no. 1, pp. 33–51. Beaglehole, Robert and Derek Yach (2003). ‘Globalisation and the Prevention and Control of Non-Communicable Disease: The Neglected Chronic Diseases of Adults.’ Lancet, vol. 362, pp. 903–908. Cooper, Andrew F. (2007). Celebrity Diplomacy. (Boulder: Paradigm Publishers). Cooper, Andrew F., John J. Kirton, and Ted Schrecker, eds. (2007). Governing Global Health: Challenge, Response, Innovation. (Aldershot: Ashgate). Dodgson, Richard, Kelley Lee, and Nick Drager (2002). ‘Global Health Governance: A Conceptual Review.’ World Health Organization and London School of Hygiene and Tropical Medicine, Geneva. <whqlibdoc.who.int/publications/2002/a85727_eng.pdf> (September 2008). Drager, Nick and Robert Beaglehole (2001). ‘Globalization: Changing the Public Health Landscape.’ Bulletin of the World Health Organization, vol. 79, no. 9, p. 803. <www.who.int/ bulletin/pdf/2001/issue9/bu1488.pdf> (September 2008). Fidler, David P. (2001). ‘The Globalization of Public Health: The First 100 Years of International Health Diplomacy.’ Bulletin of the World Health Organization, vol. 79, no. 9, pp. 842–849. Fidler, David P. (2004). ‘Germs, Governance, and Global Public Health in the Wake of SARS.’ Journal of Clinical Investigation, vol. 113, no. 6, pp. 799–804.

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Fidler, David P. (2007). ‘Architecture amidst Anarchy: Global Health’s Quest for Governance.’ Global Health Governance, vol. 1, no. 1. (September 2008). Fidler, David P. (2008). ‘A Theory of Open-Source Anarchy.’ Indiana Journal of Global Legal Studies, vol. 15, no. 1, pp. 259–284. Fidler, David P. and Laurence O. Gostin (2006). ‘The New International Health Regulations: An Historic Development for International Law and Public Health.’ Journal of Law, Medicine, and Ethics, vol. 34, no. 1, pp. 85–94. Garrett, Laurie (1996). ‘The Return of Infectious Disease.’ Foreign Affairs, vol. 75, no. 1, pp. 66–79. <www.foreignaffairs.org/19960101faessay4172/laurie-garrett/the-return-ofinfectious-disease.html> (September 2008). Garrett, Laurie (2007). ‘The Challenge of Global Health.’ Foreign Affairs. <www. foreignaffairs.org/20070101faessay86103/laurie-garrett/the-challenge-of-global-health. html> (September 2008). Godlee, Fiona (1994). ‘The World Health Organization: WHO in Crisis.’ British Medical Journal, vol. 309, pp. 1424–1428. Goodman, Neville (1971). International Health Organizations and Their Work. (London: Churchill Livingston). Gostin, Laurence O. (2004). ‘International Infectious Disease Law: Revision of the World Health Organization’s International Health Regulations.’ Journal of the American Medical Association, vol. 291, no. 21, pp. 2623–2627. Harrison, Mark (2006). ‘Disease, Diplomacy, and International Commerce: The Origins of International Sanitary Regulation in the Nineteenth Century.’ Journal of Global History, vol. 1, no. 2, pp. 197–217. Homer-Dixon, Thomas (2001). The Ingenuity Gap: Can We Solve the Problems of the Future? (Toronto: Vintage). Keohane, Robert and Joseph Nye (1977). Power and Interdependence: World Politics in Transition. (Boston: Little, Brown). Kickbusch, Ilona (2000). ‘The Development of International Health Policies—Accountability Intact?’ Social Science and Medicine, vol. 51, no. 6, pp. 979–989. Kickbusch, Ilona and Evelyne de Leeuw (1999). ‘Global Public Health: Revisiting Healthy Public Policy at the Global Level.’ Health Promotion International, vol. 14, no. 4, pp. 285–288. Kirton, John J. (1993). ‘The Seven Power Summits as a New Security Institution.’ In D. Dewitt, D. Haglund, and J.J. Kirton, eds., Building a New Global Order: Emerging Trends in International Security, pp. 335–357. (Toronto: Oxford University Press). Kirton, John J. (2007). Canadian Foreign Policy in a Changing World. (Toronto: Thomson Nelson). Kirton, John J. (forthcoming). Global Health. (Aldershot: Ashgate). Krasner, Stephen D. (1983). International Regimes. (Ithaca, NY: Cornell University Press). Labonté, Ronald and Ted Schrecker (2004). ‘Committed to Health for All? How the G7/8 Rate.’ Social Science and Medicine, vol. 59, no. 8, pp. 1661–1676. Morgenthau, Hans Joachim (1948). Politics among Nations: The Struggle for Power and Peace. (New York: Knopf). Osterholm, Michael T. (2005). ‘Preparing for the Next Pandemic.’ Foreign Affairs, vol. 84, no. 4, pp. 24–37. <www.foreignaffairs.org/20050701faessay84402/michael-t-osterholm/ preparing-for-the-next-pandemic.html> (September 2008).

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Peterson, Susan (2002). ‘Epidemic Disease and National Security.’ Security Studies, vol. 12, no. 2, pp. 42–81. Price-Smith, Andrew (1999). ‘Ghosts of Kigali: Infectious Disease and Global Stability at the Turn of the Century.’ International Journal, vol. 54, no. 3, pp. 426–442. Smith, Richard, David Woodward, Arnab Acharya, et al. (2004). ‘Commmunicable Disease Control: A “Global Public Good”.’ Health Policy and Planning, vol. 19, no. 5, pp. 271–278. Soper, George A. (1919). ‘The Lessons of the Pandemic.’ Science, vol. 49, no. 1274, pp. 501–506. t’Hoen, Ellen (2002). ‘TRIPS, Pharmaceutical Patents, and Access to Essential Medicines: A Long Way from Seattle to Doha.’ Chicago Journal of International Law, vol. 3, no. 1, pp. 27–46. Taylor, Allyn L. (2004). ‘Governing the Globalization of Public Health.’ Journal of Law, Medicine, and Ethics, vol. 32, no. 3, pp. 500–508. Thomas, Caroline and Martin Weber (2004). ‘The Politics of Global Health Governance: Whatever Happened to “Health for All by the Year 2000”?’ Global Governance, vol. 10, pp. 187–205. Trouiller, Patrice, Piero Olliaro, Els Torreele, et al. (2002). ‘Neglected Diseases and Pharmaceuticals: Between Deficient Market and Public Health Failure.’ Lancet, vol. 359, no. 9324, pp. 2188–2194. Widdus, Roy (2001). ‘Public-private partnerships for Health: Their Main Targets, Their Diversity, and Their Future Directions.’ Bulletin of the World Health Organization, vol. 79, no. 8, pp. 713–720. World Health Organization (1986). Ottawa Charter for Health Promotion. (Geneva: World Health Organization). <www.who.int/healthpromotion/conferences/previous/ottawa/en> (September 2008). World Health Organization (2001). ‘Global Health Security: Epidemic Alert and Response.’ WHA54.14, 21 May. Geneva. (September 2008). World Health Organization (2006). ‘Constitution of the World Health Organization.’ 45th ed. Geneva. <www.who.int/entity/governance/eb/who_constitution_en.pdf> (September 2008).

Part II Responding to Pandemics: Severe Acute Respiratory Syndrome

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Chapter 2

Epidemic of Fear: SARS and the Political Economy of Contagion Andrew T. Price-Smith and Yanzhong Huang

Great catastrophes may not necessarily give birth to genuine revolutions, but they infallibly herald them and make it necessary to think, or rather to think afresh, about the universe. —Fernand Braudel Catastrophes act as the principal catalysts of change, in the belief structures of those individuals who weather a given crisis, in the macro-level social structures of affected societies, or indeed in the relations among sovereign states. The emergence and diffusion of infectious disease on a global scale create a process that has been underway since the beginnings of intercontinental trade, as plague bacilli came to Europe via the Silk Road and Europeans bequeathed the terrible gift of smallpox to Amerindian populations with their discovery of the Americas (McNeill 1977; Crosby 1986). Public health victories against microbial adversaries reached a zenith in the mid 1970s; however, the pace and intensity of pathogen emergence have increased with the emergence of HIV, bovine spongiform encephalopathy (BSE), West Nile virus, severe acute respiratory syndrome (SARS), and virulent H5N1 influenza. Modern processes associated with continuing disease emergence include environmental degradation, the increased speed and magnitude of international trade and tourism, conflict, and inequities in the international distribution of resources between developed and developing countries.1 During the era of the Cold War, public health issues were typically consigned to the realm of ‘low politics’, with the exception of biological weaponry. With the end of superpower rivalry in the 1990s, issues of low politics, such as environmental change, terrorism, migration, and public health, began to ascend on the international agenda. The rise of HIV/AIDS as a threat to the economy, governance, and, perhaps, the security of societies in the developing world has galvanised the academic and policy communities, as well as many nongovernmental organisations (NGOs), into action against this emerging foe. The SARS epidemic of 2002–03 provided another example of the importance of public health as an international concern in this increasingly complex and interdependent world.

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During the outbreak, SARS produced significant levels of fear and psychological trauma in affected populations, impeded international trade and migration flows, and resulted in significant economic damage to the economies of many Pacific Rim countries (particularly China and Canada). This chapter argues that SARS generated substantial institutional innovation at the domestic level (particularly in China and Canada), while generating a powerful yet ephemeral change at the level of global governance.

Demographic Impact and Aetiology Despite the fact that the SARS epidemic threatened the economies of seriously affected states and posed a grave threat to the health of populations in the region, it was successfully contained with relatively little mortality. Specifically, the epidemic resulted in 8422 cases of infection (morbidity) and 916 deaths (mortality) between 1 November 2002 and 7 August 2003, exhibiting a mortality rate of approximately 10.88 percent (World Health Organization [WHO] 2003a). The SARS coronavirus is thought to be a novel zoonotic pathogen that recently crossed over from its animal reservoir (in which it had apparently gone from bats to civet cats) into humans (Peiris, Lai, and Poon 2003). It is imperative to note that the damage generated by the epidemic was not so much the result of the morbidity and mortality that SARS induced, but rather the fear and panic that the epidemic generated, both within infected areas and in uninfected populations.2 This fear resulted in sub-optimal economic outcomes for the entire Pacific Rim as tourism ground to halt, international trade flows were slowed, and foreign investors cautiously withdrew from the region during the crisis.

Literature Review For the catastrophe was so overwhelming that men, not knowing what would happen next to them, became indifferent to every rule of religion or of law … Athens owed to the plague the beginnings of a state of unprecedented lawlessness. Seeing how quick and abrupt were the changes of fortune … people now began openly to venture on acts of self-indulgence which before then they used to keep in the dark … As for what is called honour, no one showed himself willing to abide by its laws, so doubtful was it whether one would survive to enjoy the name for it … No fear of god or law of man had a restraining influence. As for offences against human law, no one expected to live long enough to be brought to trial and punished. —Thucydides

The study of the role of public health and international relations theory has its genesis in Thucydides’ account of the plague of Athens, wherein he observed the withering effect of contagion upon the governance of the Athenian city-state.

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Historians, including William McNeill (1977) and Alfred Crosby (1986), continued this discourse, noting the perennial influence of pathogens (and their vectors of transmission) upon the course of history and the fate of states (Diamond 2005). This historical tradition constitutes the theoretical bedrock for the investigations launched by political scientists who began their inquiries in the latter half of the 1990s (Pirages 1996; Price-Smith 1999). The nascent field of health security enjoyed a pronounced increase in salience in 2000, as the U.S. National Intelligence Council (2000) issued its National Intelligence Estimate on the threat that infectious disease posed to U.S. material interests. The inexorable expansion of the HIV/AIDS pandemic throughout the latter half of the 1990s resulted in the epidemic being designated a major threat to global security by the United Nations Security Council (UNSC) in 2000. This dramatic rise in the significance of global public health issues was augmented by the anthrax bioterror attacks of 2001 in the United States, and resulted in efforts by the academic and policy community to link health concerns to foreign policy and national security. In the post–September 11 era there has been a surge of scholarly activity in the field of health and international affairs. Such investigations have identified the emergence and recrudescence of pathogens as a threat to the economies, governance, and security of states and their populations (Price-Smith 1999; Peterson 2002; Singer 2002). Those who advocate a state-centric view see contagion as a significant threat to the material interests of the state such as its population base, economy, trade, foreign investment, the capacity of the military, and the apparatus of governance. This school perceives the state as motivated by self-interest to protect its power base, which by extension entails the protection of the health of its populace from pathogenic depredation. Due to the comparatively recent emergence of the SARS coronavirus, literature on the political dimensions of the epidemic is sparse. Elizabeth Prescott (2003) argues that the SARS epidemic illustrates the increasingly acute nature of complex interdependence among states in the domain of public health, and provides lessons that may help states in their efforts to prevent bioterrorist attacks. She observes that the emergence of the contagion ‘illuminated significant and vital weaknesses in global and local preparedness for surprise outbreaks’ (211). Melissa Curley and Nicholas Thomas (2004) argue that infectious diseases (the SARS outbreak in particular) represent a significant and growing threat to human security in southeast Asia, while David Fidler (2004) conceptualises SARS as a threat to the material interests of the state, which would seem to fit classical realist models. A classical (or republican) realist perspective views epidemic disease as a distinct threat to the material and perhaps ideational interests of the sovereign state, through its destruction and debilitation of the populace, disruption of institutions of governance, and generation of fear that erodes prosperity.3 A caveat, however, is required: even though classical or republican realism supports the notion of disease as a threat to the material interests (i.e., to prosperity and governance) of the state, strategies of self-help in an increasingly globalised world are likely to be less than effective. This is particularly true of countries in the developing world that possess lower

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levels of endogenous capacity to respond to disease outbreaks (Price-Smith 2008). Ethnocentric visions of global health that exclusively advocate self-help, to the exclusion of building capacity in the developing world, are myopic. This suggests that while realism is a useful lens through which to view the challenge posed by contagion, liberal institutional recommendations and the acceleration of international cooperation are the means by which to maintain surveillance and containment of pathogens effectively on a global scale.4 The emergence of the SARS pathogen in China and later in Canada demonstrates that both developing and highly developed G8 countries remain vulnerable to emerging and re-emerging pathogens. The emergence of BSE in the United Kingdom in the mid 1990s, its subsequent spread throughout the European community, and its extension to Japan, Canada, and the U.S. form a vivid illustration that developed countries are not immune to the deleterious effects of novel epidemic disease agents. Due to the processes of microbial evolution, pathogens will continue to evolve rapidly and colonise ecological niches within all human societies. Theoretical Ramifications The central problem is that existing theories of international relations do not deal well with the problem of the global proliferation of pathogens. Ernst Haas (1964) advocated a functionalist paradigm, stipulating that incremental progress in cooperation between states on technical issues would produce radiating effects to generate protoregimes. The economist Joseph Schumpeter (2005) argued that catalytic events and processes could generate ‘creative destruction’ wherein dysfunctional institutions were dissolved and replaced with more effective successors. In a Schumpeterian sense epidemics have generated profound disruptions, but have often acted as catalysts of change as well, generating transformation in the belief structures of policy makers, in the economic and social structures of affected polities, in the relations between society and the state, and, ultimately, among sovereign states. In fact, in light of the historical evolution of public health regimes, it becomes apparent that the process is primarily driven by a dynamic of punctuated equilibrium (PE).5 PE theory essentially holds that the progress of human societies (and institutions) is in fact non-linear, and that the evolution of a given society depends heavily upon its reaction to exogenous shocks that destabilise the pre-existing order, undercutting the legitimacy and cohesion of social hierarchies.6 This PE paradigm is more compelling than functionalist paradigms because it accounts for the reactionary and non-linear spurts of human social ingenuity that modify structures of governance at both the inter-state and intra-state levels.7 The SARS epidemic of 2003 provides additional evidence to support PE theory in the domain of political science. The outbreak of SARS in China in late 2002 and its spread throughout the Pacific Rim in the first half of 2003, is a good example of an exogenous shock. Specifically it destroyed the mythology (prevalent at the time) that infectious disease was primarily a concern for the developing countries of the

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world, which possessed limited levels of endogenous state capacity.8 The infection of populations in Canada, Hong Kong, and Taiwan by the SARS coronavirus illustrated a central component of public health: microbes evolve to colonise all available ecological niches (Morse 2001). Therefore, as a result of the SARS contagion, developed countries realised that they too were vulnerable to the proliferation of debilitating and lethal pathogens. Political theories of PE have been utilised with increasing frequency in the realm of comparative politics (Skocpol 1985) and recently in the realm of international relations theory. Robert Jervis (1997, 39) argues that ‘jumps rather than smooth progressions often characterize operations of systems … [and] when variables interact in a non-linear manner, changes may not be gradual. Instead, for a prolonged period there may be no apparent deterioration, followed by a sudden collapse or transformation’ (see also Blyth 2002; Diehl and Goertz 2000). Stephen Krasner (1984, 240) concurs, stating that ‘studies of political development point to differential rates of change in social and political structures over time’. Such models typically hold that a shock may destabilise the status quo, generating in response a burst of human social and technical ingenuity and significant incentives for international cooperation (Homer-Dixon 2001). However, following this burst of ingenuity, there follows a plateau during which concern over the issue of public health declines, only to awaken during the next crisis situation. Therefore, PE models are optimal for explaining the evolution of public health as an issue in the domain of international relations. To date, theories of international relations have a rather difficult time integrating the growing threat of epidemic disease, which originates at the domestic level but may subsequently manifest as an externality at the global level in the form of pandemic disease. If such a non-linear (PE) perspective is adopted, then the evolution of structures of governance in the face of epidemic disease might best be understood as following the trajectory of a PE model. In this instance, an exogenous shock challenges the capacity and resilience of a state (or system). If the populace is innovative and hardy, and apparatus of governance flexible (i.e., it possesses sufficient endogenous capacity), then the state will survive. In a Darwinian sense the shock generates a spurt of ingenuity that propels a given society to a higher level of social and technical innovation. However, states that possess lower endogenous capacity, and therefore lack resilience, will succumb and falter, periodically disintegrating into a state of chaos, stabilising, and then failing again. As William Zartman (1995) argues, it is a process akin to that of a ball falling down a set of stairs, a descent followed by partial stabilisation, only to be followed by another plunge. A rational critique of such a PE model might argue that the role of epistemic communities would be valuable in explaining the role of cooperation, in that microbiologists effectively communicated their concerns to decision makers who then modified existing regimes to deal with forthcoming epidemics. Unfortunately, such a proactive model is not borne out by historical evidence, as nations typically exhibit reactive and not proactive stances regarding disease surveillance and control. Epistemic communities have been successful in generating change based on two

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principal factors: first, the existence of a real threat to the material interests of a given state as a result of epidemic disease and, second, the interpretation of the scientific communities concerns into the language of materialism and national security by the policy community in order to galvanise political action.

On Materialism and Fear The actions taken by the policy community, such as improved global pathogen surveillance systems and public health regimes, are then the product of two central factors, namely materialism and fear. Epidemics have historically generated extraordinary levels of affect (i.e., emotion) within involved populations, leading to generalised economic and social chaos within the states direclty involved, and to quarantine and trade embargo (i.e., isolation) by other states that fear the spread of contagion. The emergence of a novel pathogen is accompanied by high levels of uncertainty regarding its virulence, transmissibility, and aetiology. This uncertainty generates high levels of negative affect (fear), which in turn generates very real damage to a state’s material interests, over and above the actual morbidity and mortality that result from the epidemic. The SARS epidemic provides a vivid illustration of this paradigm wherein the emergence of the SARS coronavirus, coupled with seemingly high levels of both virulence and transmissibility, combined to generate extreme levels of anxiety throughout the entire Pacific Rim community. Major epidemics have historically produced significant worry, anxiety, fear, panic, and even mass hysteria in an affected society. Depressed and helpless, victims and survivors may heavily discount their future and engage in all kinds of risky behaviour, such as crimes and riots, that put the social fabric to a severe test. Confused and shocked, people may turn to superstitious or bizarre practices during an outbreak. Moreover, fear and panic generated by the disease can also take the form of mass exodus. For example, when plague struck Surat, a city in the western part of India in 1994, the fear of an epidemic was so intense that 500 000 residents fled in less than a week. A series of factors exacerbated SARS-associated fear and panic during the course of the contagion. First, the virus is highly pathogenic and contagious as the main route of transmission was direct contact, via the eyes, nose, and mouth, through infectious respiratory droplets. Unlike the threats of HIV/AIDS, it is difficult to control the behaviour that caused the transmission of the disease. Second, the disease exhibited relatively high levels of mortality in infected hosts. The morbidity rate of 10.88 percent is significantly higher than the 2.5 percent case fatality rate for the 1918 Spanish influenza, which led to the death of approximately 50 million people worldwide (Johnson and Mueller 2002; Taubenberger and Morens 2006). Third, SARS is an indiscriminate killer that affected all classes, genders, and ethnicities. The contagion was reported to have passed through the exclusive Zhongnanhai compound, the headquarters of China’s Communist Party.

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Moreover, the fact that SARS was an entirely novel pathogen meant that public health personnel did not have a clear idea of the symptoms, routes of transmission, and effective prevention of transmission during its outbreak. This uncertainly not only resulted in diagnostic delays or misdiagnosis, but also put healthcare workers at particular risk. Witnessing that nurses and doctors were unable to protect themselves from the infection, the public developed a highly exaggerated estimate of their personal risk of being infected. A nationwide survey of 1026 respondents in China found that manifestations of panic were exhibited by 19 percent of the people in areas with local transmission and 11 percent of the people in areas without local transmission.9 Similarly, an online internet survey of 1070 students of the University of Hong Kong between 16 April and 22 April 2003 found a profound level of stress (49 percent) among the respondents (Chan 2003). Within the People’s Republic of China (PRC), a governmental information clampdown and a fatal period of hesitation further magnified levels of fear and anxiety, leading to widespread speculation and rumour mongering. As early as 8 February, reports about a ‘fatal’ influenza began to be sent via short messages on mobile phones in Guangzhou, capital of Guangdong province (‘Officials Need to Stay on Top of Rumour Mill’ 2003). Soon, residents in Guangzhou and other cities cleared pharmacy shelves of antibiotics and influenza medication. In some cities, even vinegar, believed to be a disinfectant, was sold out. The panic spread quickly to other provinces as well. Farmers in many provinces set off firecrackers in the belief that would frighten off SARS. In the northwestern province of Shaanxi, farmers invited sorcerers and sorceresses into their homes to help them exorcise the flu-like virus. At the height of the epidemic in Beijing, a sea of people in white masks—most of them scared migrant workers and university students—flocked to train and bus stations and airports in the hope of fleeing the city. By late April, an estimated 1 million people, around 10 percent of the population, had fled the city for other parts of China. They would soon find themselves personae non gratae even in their hometowns. In the countryside, worried villagers set up roadblocks to keep away people from Beijing. A series of riots against quarantine centres were also reported in May. This fear resulted in substantial negative economic impacts on affected nations. The rapid spread of the lethal disease and the perceived high risk of social interactions led people in affected regions to alter their daily routines and leisure habits. Restaurants, air-conditioned shopping malls, and public entertainment venues such as theatres and internet cafés were either closed or avoided. Meanwhile, fear of contagion and the implementation of anti-epidemic measures discouraged travel and interrupted transport services. This caused substantial decline in consumer demand in the service sector. The adverse demand shock affected two industries in particular: retail sales and tourism. By mid April 2003 retail sales in Hong Kong had declined by 50 percent relative to mid March indicators (WHO 2003c). Additionally, tourism arrivals from mainland China had fallen by between 75 percent to 80 percent, and the entertainment and restaurant industries had recorded an 80 percent decline in business. In general, the economic shock was far greater for those economies with a prominent service sector and that possessed a larger share of affected industries (i.e.,

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retail sale and tourism) within that sector. This may explain why Hong Kong, with its losses accounting for 2.9 percent of gross domestic product (GDP), suffered the worst given the size of its economy (Asian Development Bank [ADB] 2003). In early April 2003, Morgan Stanley chief economist Stephan Roach estimated the global economic cost of SARS at circa US$30 billion (WHO 2003c). The Far Eastern Economic Review later estimated initial SARS-related damage to regional GDP growth at US$10.6 billion to US$15 billion (Saywell, Fowler, and Crispin 2003). If SARS had continued to spread, quarantines could have affected manufacturing, which accounted for approximately 30 percent of Asia’s GDP (minus Japan), by closing factories and slowing trade (13). If the costs of premature deaths of income earners, lost workdays of sick employees, and health care were factored into the equation, the eventual bill for the region could total almost US$50 billion. China sustained significant losses in its service sector, which makes up 33.6 percent of the country’s GDP (China, National Bureau of Statistics 2002). SARS caused a decline in sectoral productivity of 6.8 percent during the second quarter (‘GDP Growth Revised Up for 1st Half of 2003’ 2004). According to a government economist, the loss borne by the sector was 23.5 billion yuan, including 20 billion yuan in tourism and 3.5 billion yuan in retail sales (Hu Angang and Linlin 2004). Based on the economic indicators of China’s economy affected by SARS, the Asian Development Bank (2003) put the GDP losses in China at US$6.1 billion, or 0.5 percent of total GDP. If calculated by total final expenditure, the total loss was US$17.9 billion, or 1.3 percent of China’s GDP. While the dampening of tourism and consumer confidence is the most important channel through which SARS wreaked havoc, other developments during the outbreak highlighted the fragility of China’s economy. In some regions, people rushed to purchase daily necessities, and this panic buying threatened to trigger a ‘bank run’ that could have further disrupted China’s ailing financial industry, where state-run banks were generally in poor financial shape and were frequently confronted with rumour-driven mass withdrawals. Moreover, China’s export sector—the engine of its economic growth—was threatened by calls for other countries to quarantine China, and thereby suspend all travel links with the country until it implemented a transparent public health campaign. During the crisis, 110 out of the 164 countries with which China had diplomatic relations placed at least some restrictions on travel to China (Embassy of Switzerland 2003). If SARS had persisted and disrupted the production and supply line, the increased risk profile associated with doing business in China would have led to a reduction in foreign investment and exports, which eventually would have hurt China’s manufacturing sector (which accounts for a hefty 36.8 percent of the country’s GDP) (Fei Feng 2006). The end result would be a rapid decline in the economic growth rate, on which the regime’s legitimacy hinges (see below). The emergence of HIV/AIDS was also initially accompanied by high levels of fear, but given that transmissibility is more difficult, it did not significantly compromise international trade. At this point a distinction between two types of epidemics must be made: outbreak events, such as SARS and the plague of Surat in

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1994, generate significant levels of fear, which then damages the material interests of the state (primarily economic interests); and attrition epidemics, which include the HIV/AIDS pandemic, malaria, and tuberculosis (TB), do not generate similar levels of fear as there is relatively high certainty about morbidity, mortality, and pathways of transmission regarding these pathogens. However, attrition epidemics do very much threaten the material interests of the state through the inexorable debilitation and destruction of its populace, weakening of military forces, depletion of human capital, erosion of governance capacity, and general macroeconomic decline. States will then seek to cooperate in order to limit transmission to prevent the erosion of their material interests and this becomes the basis for regime formation. In both cases a PE model remains useful, although it is more applicable to the outbreak cases. However, whereas realism and the state’s concern for its material interests would seem to be the principal motivating force impelling it to act, realism does not provide a theoretical framework that is effective in containing pathogens, particularly in the context of increasing international trade flows and migration. Sovereign states have realised that strategies of self-help are doomed to failure as borders are increasingly porous in this modern era of globalisation. Effective surveillance and containment of pathogenic threats must necessarily include high levels of cooperation with other sovereign states, as moderated by international institutions and assisted by NGOs. It is ironic then that the basis of state concern is the prism of realism, yet realist strategies of self-help will likely result in significant losses for all states, even a hegemon. Liberal strategies of cooperation among sovereign states, increased transparency, and the dissemination of information through international organisations and NGOs permit pareto-optimal outcomes not possible under realist constraints.

History of an Epidemic The epidemic of SARS began in Guangzhou in November 2002. A physician who attended the ill, Dr. Liu Jianlun, inadvertently became the index case for a global chain of transmission when he travelled to Hong Kong and unknowingly infected other travellers, who then spread the disease throughout the Pacific Rim countries (Vietnam, Canada, Singapore, Taiwan, and other regions of China). Despite attempts to suppress dissemination of epidemiological information, in February 2003 the Chinese Ministry of Health notified the World Health Organization (WHO) that 305 cases of acute respiratory syndrome (of unknown cause) had occurred in Guangdong province of southern China since November 2002. In that same month a Chinese traveller to Hanoi infected several healthcare providers there. Later that month a cluster of similar illness among healthcare workers occurred in Hong Kong. On 12 March, the WHO issued a global outbreak alert and began international surveillance efforts to track this syndrome. At that point the contagion had spread throughout the states of the Pacific Rim, with the greatest incidence of cases in China (5327), Hong Kong (1755), Taiwan (665), Canada (251), Singapore (238), Vietnam (63), and the U.S. (33) (WHO 2003d).

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Effective response to the epidemic was initially complicated by fear, confusion, and denial in China, as Beijing engaged in a deliberate attempt to suppress knowledge of the epidemic in both the domestic and international arenas. According to Yanzhong Huang (2003, 65), the first SARS case was ‘thought to have occurred in Foshan, a city southwest of Guangzhou in Guangdong province, in mid November 2002’. Reports on the spreading illness by the health authority in Guangdong province were classified as top secret by Beijing, such that the disclosure or discussion of the outbreak was a direct violation of the State Secrets Law (66). Ultimately, the epidemic generated such levels of panic among the general Chinese populace that warnings of the growing crisis leaked out through individuals on the internet. Yet Beijing persisted in its attempts to mislead the WHO. On 27 February the Chinese Ministry of Health declared the epidemic to be officially over, while the disease was actually spreading rapidly through the populace of Beijing (Fidler 2004, 75). The Chinese began to crack on 4 April, when the head of the China Center for Disease Control and Prevention (China CDC) publicly apologised to the Chinese people and international community for failing to inform the public about a highly contagious and frequently lethal new infection (Pomfret 2003b). The full extent of Beijing’s duplicity became clear when on 9 April a prominent Communist Party member (and physician), Jiang Yanyong, publicly accused the government of covering up the extent of the epidemic in Beijing (Pomfret 2003c). On 16 April the WHO took the unprecedented step of issuing a very public rebuke of China’s actions, chastising Beijing for misleading the global community regarding the true extent of SARS infection throughout that country (Pomfret 2003a). Two days later chastened national leaders announced a national war on the virus, and ordered Communist Party officials to reveal the true extent of the epidemic or be held accountable. On 20 April, the party leadership sacked the minister of health, Zhang Wenkang, and the mayor of Beijing, Meng Xuenong, for their complicity in the cover-up (Fidler 2004, 98). This move was seen as an attempt to deflect blame from senior party officials for their role in the crisis, and was summed up in the Chinese idiom ‘scaring the chickens to catch the monkey’ (Curley and Thomas 2004). Vietnam’s superior response to the outbreak resulted in that country being declared SARS free on 28 April. On 5 July 2003, the WHO announced that the SARS epidemic had been effectively contained. Despite the fact that the international community successfully contained the spread of the virus in a relatively brief span of time, the medical community insisted that it represented a significant global threat. Thomas Tsang, the epidemiologist who oversaw the investigations in Hong Kong, commented that there was a possibility of a global pandemic ‘if the appropriate control measures were not taken’ (Bradscher and Altman 2003).

Costs of the Epidemic in Canada Unfortunately, the economic effects of the SARS epidemic remain largely unknown, particularly on the Canadian economy. At the sectoral level, the SARS epidemic had a pronounced negative impact on the Canadian economy in the second and third

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quarters of 2003. Industries that bore the brunt of the contagion included tourism and hospitality and the film industry. Toronto’s film, television, and commercial business—the largest in Canada—brought in a billion dollars per year, and it was badly damaged by the epidemic of 2003, as foreign production houses withdrew their operations. According to Joe Halstead, commissioner of economic development for the City of Toronto, the SARS epidemic resulted in a decline of production, resulting in a loss of CA$163 million (roughly 18 percent) for the film sector in 2003 (Porter 2004). Commercial production in the city exhibited a similar decline of CA$32.8 million in 2003 (roughly 20 percent) (Porter 2004). These statistics were compiled from permit applications that production houses must file with the City of Toronto. Tourism in Ontario also took a significant hit as a result of the epidemic. The City of Toronto estimated a drop in tourism of 18 percent during 2003, largely as a function of the epidemic and its after effects (Porter 2004). According to Jeff Dover of KPMG, the SARS epidemic resulted in the loss of approximately CA$993 million in the tourism sector of the Canadian economy during the second and third quarters of 2003 (Spears 2003). Macro Level SARS seems to have been largely responsible for a pronounced economic downturn in Ontario, Canada’s largest province, where it resulted in two consecutive quarters of economic decline in 2003. Ontario finance minister Gregory Sorbara noted that the widespread decline was ‘an economic downturn that was driven by SARS’ (Little 2004). According to Ministry of Finance estimates, Ontario’s real GDP fell by 0.7 percent in the second quarter, and by a further 2.5 percent decline in the third quarter of 2003. Fortunately, the economy rebounded in the fourth quarter when growth reportedly increased at a rate of 4.5 percent (Little 2004). The minister of health for Ontario during the epidemic, Tony Clement, revealed that SARS had cost the province’s healthcare system CA$945 million as of 27 June 2003. Cost increases were associated with extra staffing needs, special supplies required to protect healthcare workers, and expenditures to build specialised SARS isolation and treatment facilities (Little 2004). Altogether the best-guess estimate is that the contagion cost Ontario at least CA$1.5 billion in 2003, a significant blow to the Canadian economy.

Effects on Domestic Governance in Canada Given that the SARS epidemic would seem to have ushered in a new era of increased cooperation between states for the purposes of health, it is ironic that the epidemic revealed significant problems in governance within those sovereign states most affected by the epidemic (namely Canada and China). Fidler (2004) and Huang (2003) have published exhaustive works regarding the effects of the SARS contagion on governance within China. The effects of the contagion on governance in Canada,

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and the problematic responses of the government at both the provincial and federal levels, deserve serious investigation. Specifically, in the Canadian case the epidemic revealed that Canadian public health infrastructure was fragile, particularly in the province of Ontario, which saw the most significant outbreak of SARS outside of China. Ontario experienced significant problems in infection control, ranging from the questionable leadership of Colin D’Cunha, the province’s commissioner of public health, to problems in staffing hospitals, to the persistent violation of quarantine and subsequent spread of infection. The Canadian case also illustrates chronic problems in communication between the provincial government in Toronto and the federal government in Ottawa, exacerbated by the perennial conflict over which tier of governance should preside over matters of public health. At present such duties are relegated to the provinces, as is the matter of funding supplemented by transfer payments from Ottawa. Partisan differences may have also led the Liberal federal government of Prime Minister Jean Chrétien to be less than cooperative with Ontario’s Conservative provincial government of Ernie Eaves. The Chrétien government also demonstrated a significant failure of leadership during the crisis, as the federal minister of health, Anne McClellan, often proved less than cooperative in her dealings with the province and the WHO. Moreover, Chrétien displayed a striking lack of leadership when he refused to interrupt his vacation abroad to return to Ottawa and deal with the rapidly expanding epidemic in the Greater Toronto region. As a result of these glaring deficiencies in the Canadian response to the epidemic, the SARS commission (under the stewardship of Justice Archie Campbell) determined precisely how the system failed, and developed recommendations for improving the response capacity of Canadian public health delivery (SARS Commission 2006). Prescott (2003, 218) chides Canadian officials for their limited response to the emergence of contagion in Toronto: Canadian officials appeared to be more concerned with the short-term impact of a [WHO] travel advisory on tourism, retail and other industries, even though the epidemic appeared to have spread through the community and to other countries partially because the Canadian health authorities had ignored a WHO advisory that all departing passengers from Toronto be screened by medical personnel.

Ultimately, the Canadian response to the exogenous shock of the SARS epidemic provides some evidence to confirm the PE model. Specifically, the federal government created a new Cabinet-level Public Health Agency of Canada (PHAC), led by a chief public health officer who (despite a certain degree of autonomy) reports to the minister of health. A central mission of this agency is the facilitation of cooperation between the federal and provincial governments in the domain of public health emergencies. This clearly demonstrates the increasing salience of public health issues in the mind of Canadian political elites. The SARS debacle clearly resulted in the elevation of public health to the level of ‘high politics’ in Ottawa. This is evident in the reference in the report of Canada’s National Advisory Committee on SARS and Public Health (2003, 220) to Benjamin Disraeli’s argument that ‘public health was the foundation

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for “the happiness of the people and the power of the country. The care of the public health is the first duty of the statesman.”’

Effects on Domestic Governance in China While the epidemic inflicted significant short-term economic damage to Pacific Rim economies, it also had important implications for intra-state governance. The SARS epidemic exposed significant problems in China’s governance structure. Initially, the government chose not to publicise the outbreak for fear that this would have a negative impact on economic development. The information clampdown persisted even after the epidemic spread to Beijing, in part because the party-state did not want SARS to ruin the meeting of the National People’s Congress (NPC), a showcase for its highly controlled and carefully staged version of participatory democracy. By early April, it was evident that SARS had already raised the eyebrows of the central leaders. Yet the government’s ability to formulate a sound policy against SARS was impeded by lower-level government officials who intercepted and distorted the information flow up the chain of command. It was alleged that Beijing municipal authorities, for example, deliberately hid the actual SARS situation in the city from the party centre. Initial deception by lower-level officials led the central leaders to misjudge the situation and declare on 2 April that SARS had already been brought under effective control. The cover-up paralleled the absence of effective official response to the original outbreak. As late as 20 January the ministry of health was aware that a dangerous new type of pneumonia existed in Guangdong. However, China CDC did not issue a nationwide bulletin to hospitals on how to prevent the ailment from spreading until 3 April. It was not until mid April that the government formally listed SARS as a disease to be closely monitored and reported on a daily basis under the Law of Prevention and Treatment of Infectious Diseases. The Chinese government thus waited more than three months before taking decisive action. This lack of ‘sensitivity’ was to large extent caused by the problem of ‘connectivity’ (i.e., interdepartmental cooperation). In addition to the tensions among different levels of health authorities, coordination problems existed between functional departments and territorial governments, and between civilian and military institutions. Organisational barriers also delayed the process of correctly identifying the cause of the disease. In fact, China CDC had to negotiate with local disease-control centres to obtain the virus samples. As the number of new cases in Beijing grew rapidly, a significant burden was imposed on the healthcare system, particularly its hospital capacity. Overwhelmed by the extraordinarily high flow of traffic through emergency rooms in mid April, major hospitals in Beijing took few measures to reduce the chances of cross-infection. The crisis raised serious concerns about the capacity of the health systems in resourcepoor regions to cope with a pathogenic challenge on the scale of SARS. Paradoxically, the SARS crisis also granted an opportunity for the Chinese government to address internal governance problems. As Albert O. Hirschman (1991)

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suggests, politicians have strong incentives to exploit crisis and danger and emphasise the risks of inaction in order to mobilise opinion and arouse action. In view of the dying communist ideology and official resistance to democracy, the legitimacy of the current regime in China is performance based, rooted in delivering economic growth. The possibility of an economic recession caused by SARS, therefore, posed a direct threat to the regime’s legitimacy. In the words of Premier Wen Jiabao, ‘the health and security of the people, overall state of reform, development, and stability, and China’s national interest and international image now are at stake’.10 This perceived crisis impelled the central leaders rally the full potential for autonomous action. On 17 April the PRC’s national leaders convened an urgent meeting to kick off a national war on the epidemic. This dramatic policy switch was accompanied by a significant relaxation of media control as government media began to publicise the number of SARS cases in each province, updated daily. The crisis also led to government efforts to increase bureaucratic control and earmark more financial resources for anti-SARS campaign. On 23 April, a task force known as the SARS Control and Prevention Headquarters of the State Council was established to coordinate national efforts to combat the disease, with Vice Premier Wu Yi appointed as commander-in-chief. The same day, a national fund of 2 billion yuan (US$242 million) was created for SARS prevention and control. As part of a nationwide campaign to mobilise the system, the State Council sent out inspection teams to 26 provinces to scour government records for unreported cases and to fire officials for lax prevention efforts. According to the official media, by 8 May China had sacked or penalised more than 120 officials for their ‘slack’ response to the SARS epidemic. These actions shook the complacency of local government officials, who then abandoned their initial hesitation and jumped onto the anti-SARS bandwagon. With the intensive and direct involvement of the party centre, maximum interagency and intergovernmental cooperation were achieved. Indeed, it took only one week for China to construct and put into operation a SARS hospital that had the capacity to accommodate 1200 patients. In addition to this augmentation of state capacity, the crisis apparently forced the government to take steps to establish an image of a more open and transparent government.11 On 2 May the official Xinhua news agency reported a submarine accident in April that had cost 70 lives, which marked a significant departure from the traditionally secretive approach taken to the nation’s military disasters. The SARS transparency campaign also provided incentives to be more open in dealing with other infectious diseases. After July 2003, information on current veterinary epidemics, such as foot and mouth diseases, swine vesicular disease, and avian influenza were no longer classified as state secrets. In retrospect, the SARS crisis challenged the traditional concept of governance in China and helped to elevate the status of public health significantly on the government’s agenda. The government has now realised that economic development does not trickle down, and that public health should be treated as an independent criterion of good governance. Premier Wen said that ‘one important inspirational lesson’ the new Chinese leadership learned from the SARS crisis was that any

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‘imbalance between economic development and social development’ was ‘bound to stumble and fall’.12 The government since then has earmarked billions of dollars for the public health sector. On various occasions since the crisis, central leaders have emphasised the importance of public health, especially public health emergency response. The government capacity to mobilise against a disease outbreak is enhanced by a more institutionalised crisis management system. The Regulations on Public Health Emergencies issued by the State Council in mid May 2003, for example, require setting up an emergency headquarters right after a public health emergency is identified. By the end of 2005, 66 percent of the township and health centres, 90 percent of the health institutions at or above county level and 100 percent of the centres for disease control had built the internet-based disease reporting system, allowing hospitals to report suspected infectious disease cases directly to China CDC and the ministry of health. The epidemic also created incentives for Chinese leaders to show a new, more proactive attitude toward AIDS. Since then, discourse and action relating to HIV/AIDS have changed dramatically, with senior leaders facing the epidemic with a greater sense of awareness, openness, and responsibility. The Chinese case underscores the importance of democratic values in good governance, but democracy itself is not sufficient for effective governance during public health crises. In this regard, Canada provides a very good example that even an advanced democracy can experience serious problems in public health governance. Indeed, SARS revealed the limitations of the country’s expensive system of universal health care, prompting the federal and provincial governments to review the public health policies and infrastructure. The effects of the contagion on governance in Canada, and the problematic responses of the government at both the provincial and federal levels, therefore deserve serious investigation. Specifically, in the Canadian case the epidemic revealed that Canadian public health infrastructure was fragile, particularly in the province of Ontario, which saw the most significant outbreak of SARS outside of China. Gambling that budget cuts in public health controls would not matter, the Conservative provincial government in 2001 laid off five scientists charged with disease surveillance. Public health disasters, such as the infection of the water supply in Walkerton, Ontario, with E. coli went unheeded by a government bent on cost cutting. The provincial government subsequently paid an onerous price for such short-sightedness, complacency, and thoughtlessness. Effects on Regional Governance in the Pacific Rim As the SARS epidemic intensified, the members of the Association of South East Asian Nations (ASEAN) grew increasingly aware of the threat the contagion posed to their populace and their economies. Anxiety in this region was reinforced by prior shocks to governance, such as the Asian financial crisis of 1997–98, as well as the regional environmental effects of the haze from ubiquitous fires throughout the region during the same time. As Prime Minister Goh Chok Tong of Singapore admitted, SARS had a bigger impact on the country than the 1997–98 financial

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crisis: the country suffered only ‘collateral damage’ during the financial crisis, but this time its economy (notably tourism) was directly hit, and there was a danger of ‘total shutdown’ (‘The SARS Outbreak—Interview: Goh Chock Tong, Leading the Charge against SARS’ 2003). Indeed, fear arose in Singapore that SARS could provoke its worst crisis since independence in 1965. Singapore, of course, was not the only country that worried about SARS. As a global alert had been sounded on the disease, many travellers were avoiding Asia indiscriminately, which translated to a significant drop in tourist revenue. As Thai prime minister Thaksin Shinawatra astutely noted, ‘the fear of SARS is worse than SARS itself’ (Crampton 2003). While concerns of economic loss were shared by leaders throughout the region, the rapidly spreading epidemic also generated a strong sense of urgency for regional cooperation. On 26 April, the health ministers of ASEAN +3 (China, Japan, and South Korea) met in Kuala Lumpur to voice their willingness to cooperate. Subsequently, leaders from the ten ASEAN members attended an emergency summit in Bangkok on 29 April. The Bangkok Summit was initiated by Goh Chok Tong, who was also instrumental in framing the agenda. ASEAN became the ideal platform for discussing this issue. According to Goh, he first called leaders of three countries—Malaysia, Thailand, and Cambodia (which held the chair of ASEAN in 2003); once they agreed on the necessity of having such a meeting, he called all the other ASEAN leaders. Unlike previous Asian summits, which generated more rhetoric than action, the final communiqué of the Bangkok Summit stated that there was a ‘collective responsibility to implement stringent measures to control and contain the spread of SARS and the importance of transparency in implementing these measures’ (ASEAN 2003). ASEAN members agreed that all states in the region would immediately commence mandatory screening for SARS at their borders. The declaration further agreed on various measures to stop SARS transmission, including: • sharing information on the movement of people by building a SARS containment information network; • coordinating prevention measures by standardising health screening for all travellers (i.e., common protocols for air, land, and sea travel) and adopting an isolate-and-contain approach (rather than a blanket ban on travel) in SARS control; • establishing an ad hoc ministerial-level joint task force to decide on and monitor the implementation of the decisions made at the April 2003 meeting and the ASEAN+3 health ministers special meeting on SARS. China and representatives from Hong Kong were invited that same day to attend a follow-up summit. Recognising that the cross-boundary spread of SARS posed a common challenge to the region, Chinese premier Wen made it clear that the disease could ‘only be effectively countered by cooperative efforts at the regional and international levels’.13 The domestic–international linkage also created strong incentives for China to cooperate with ASEAN countries. Before the Bangkok Summit, Chinese leaders were already under fire in Asia for orchestrating an official

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cover-up of the disease. By calling for combating SARS in a ‘transparent and effective manner’, southeast Asian states subtly intervened in China’s domestic affairs as a compensation for their weakness at the international level (ASEAN 2003). During this special ASEAN-China leaders meeting, however, ASEAN diplomats were very careful not to criticise Beijing’s mishandling of the epidemic directly, but rather to seek China’s cooperation in dealing with a highly sensitive issue. The idea was for ASEAN leaders to agree on a set of resolutions and measures for China to sign on to. On the part of China, once the power succession issues were resolved in the NPC meeting and a consensus was reached among political elites on the urgency and the necessity for action, the government was ready to ‘face reality and the world courageously and responsibly’ (Ching Cheong 2003). Keenly aware that the image of the country and the reputation of the new leadership were at stake, Wen was very open, candid, and cooperative at Bangkok. In the joint statement, China agreed to ‘associate itself with the measures proposed by the ASEAN declaration’ (Vatikiotis 2003). This seemingly half-hearted endorsement was indeed remarkable, given that a total embracement of the measures decided by the ASEAN leaders would be perceived in China as an act of submission. To demonstrate its commitment to cooperate with ASEAN countries, China proposed the creation of a special fund to support a variety of bilateral programmes with the ASEAN countries against the SARS contagion. Ultimately the Bangkok Summit proved to be a win-win case for both China and southeast Asia. For leaders in southeast Asia, the health crisis reinvigorated their association and served to equalise relations with China. China, on the other hand, deftly used the new dynamics created by the summit to expand its influence in this region. In October, China became the first ever ‘strategic partner’ of the ASEAN members, which was regarded as a victory over the suspicions that ASEAN members have long harboured toward China because of territorial disputes and ideological conflicts. In the words of Singaporean prime minister Goh Chok Tong, the SARS crisis may have been ‘the start of a new relationship between leaders in East Asia’ (Vatikiotis 2003). Another lesson of the epidemic was that despite ASEAN’s development of significant cooperative arrangements regarding containment of the epidemic, it remained the responsibility of its sovereign member states to implement those principles and to engage in suppression of the contagion. Moreover, the rapid response of ASEAN leaders and their willingness to cooperate in the containment of SARS were doubtless influenced by prior shocks to governance in the region such as the Asian financial crisis of 1997–98, as well as the regional environmental effects of the fires raging at that time. These shocks had generated incentives for ASEAN countries to become increasingly cooperative in managing complex transboundary issues.

Effects on International Health Governance Prior to the emergence of SARS, international health regimes (as governed by the International Health Regulations [IHR]) were seriously dated, for two reasons. First,

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since their inception in 1951 (in the form of the International Sanitary Rules), the IHR had not been revised adequately in the face of emerging novel pathogens. The IHR required the reporting of only three infectious diseases: cholera, plague, and yellow fever. Second, under the IHR the reporting of pathogen-induced morbidity and mortality was exclusively the domain of sovereign states. Historically, states have long sought to suppress the flow of information regarding endogenous epidemics, because the emergence of contagion typically generates significant negative effects upon the economy and society of infected states. Such pernicious effects range from the collapse of tourism to the decline in foreign investment, to the embargo of trade goods from affected nations. Thus states have had significant material incentives not to report the occurrence of epidemics accurately to the global community. In this sense, Beijing’s early attempts to suppress the flow of information to the WHO and Canadian officials’ insistence that WHO travel advisories were erroneous both reflect this historical pattern of tension between sovereign states and the WHO. Despite these problems, some important changes have taken place in international health governance regime since the 1970s as a result of technological advances, the rise of new and re-emerging infectious diseases, and the increasing involvement of non-state actors in addressing global microbial threats. At first glance, the SARS epidemic appeared to confirm the transition to new forms of health governance, described by Fidler (2004, 7) as ‘the post-Westphalian era’ in which non-state actors have increasing influence on global governance. During meetings of the World Health Assembly (the WHO’s supreme governing body) in May 2003, member states stipulated that the organisation should redouble its efforts to collect and analyse data from non-state actors. Specifically, the assembly requested that the director general of the WHO (2003b) ‘take into account reports from sources other than official notifications’. The advent of non-state actors’ ability to communicate data directly to the WHO appears to have undermined the historical monopoly of sovereign states regarding the reporting of public health information. However, this is likely a function of the geographical emergence of SARS in the relatively advanced areas of East Asia, where access to communications technology is ubiquitous. Fidler’s arguments are weakened by the lack of substantive and effective cooperation between sovereign states, NGOs, and international organisations in the realm of other infectious diseases such as malaria, TB, and, particularly, HIV/AIDS. Therefore, the SARS epidemic appears to have temporarily increased the power and authority of the WHO vis-à-vis the sovereign state. As a result of non-state regulated information flows, the WHO found itself no longer in a subservient position relative to sovereign state actors. The organisation employed this newfound freedom to issue global alerts and travel advisories when it deemed appropriate and was not subject to the consent of affected member states. It issued its first global alert on 12 March 2003, in order to make the international community aware of the expanding SARS contagion. The organisation subsequently issued specific advisories that travellers postpone all non-essential travel to affected regions such as Toronto, Hong Kong, Guangdong, and Beijing. It is noteworthy that neither the WHO constitution nor the IHR invested the organisation with this power. Furthermore, the WHO travel

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advisories were specifically directed at travellers (i.e., individuals) and not at states. During this brief moment, global health governance temporarily shifted to a new configuration wherein non-state actors provided WHO with information, which was then analysed by the organisation and subsequently disseminated to global civil society without the consent or even the consultation of targeted countries. However, Fidler’s arguments that there is today a transformative order that effectively limits the sovereign state’s ability to compromise the process are overstated. In the domain of HIV/AIDS, the sovereign state is very much capable of thwarting international efforts to address the spread of the contagion. One need only look at the history of obfuscation and denial generated by political leaders in sub-Saharan Africa (Thabo Mbeki and Robert Mugabe in particular) to observe this process of state obstruction (see Price-Smith and Daley 2004; Price-Smith 2002b). Indeed Andrew Price-Smith and John L. Daly (2004) demonstrate that in the case of Zimbabwe, Mugabe’s Zimbabwe African National Union–Patriotic Front regime provided antiviral therapies solely to their political supporters, denying such lifesaving pharmaceuticals to the Movement for Democratic Change, the opposition party.

Conclusion By inflicting significant socioeconomic costs on affected states, the SARS epidemic exposed the vulnerability of existing governance structures, reshaped the beliefs, norms, motivations, and preferences of those individuals who weathered the crisis, and ultimately led to macro-level changes in domestic political governance while enhancing the dynamics of regional health cooperation among the Pacific Rim states. However, SARS-induced effects on the international system and the interplay between sovereign states and international organisations were largely ephemeral. The greatest effect of SARS was not so much that it constituted a significant material threat to the prosperity, effective governance and security of states, but rather that it generated significant changes in governance within affected states (particularly in Canada and China). Conversely, and contrary to Fidler’s assertions, the epidemic does not seem to have generated significantly increased compliance of sovereign states with international health regimes (or significant revisions to the IHR for that matter). Nor has the WHO retained the expanded powers it exhibited during the SARS crisis, although it could arguably employ such strategies again to contain the growing H5N1 pandemic. So why was the response to SARS so different from the international response to other pathogens? The SARS epidemic exhibited several factors that led to the empowerment of the WHO, namely the emergence of a novel virus, coupled with seemingly high levels of virulence and transmissibility, generating high levels of uncertainty and fear. This event constituted an exogenous shock that affected regional political and economic elites and presented an immediate socioeconomic crisis for the decision makers to address at the national, regional, and international levels.

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A caveat is in order. First, this revolution in global health governance may have occurred with SARS precisely because the novel coronavirus was perceived as highly lethal and extraordinarily contagious. The inexorable spread of avian influenza has generated significant concern and a desire for international cooperation in capitals around the world. In the case of H5N1, the WHO remains very involved in directing the international efforts to contain the spread of the pathogen throughout southeast Asia, and regional governments appear to be conceding authority to the organisation. However, it is increasingly apparent that the power to contain an influenza outbreak remains in the hands of sovereign states. Furthermore, one might ask whether the international community will respond in a similar manner to other pathogens that are less lethal and less communicable (e.g., malaria and HIV). In fact, such a response has not materialised, because these latter pathogens do not generate similar levels of fear as does SARS or avian influenza. This lack of concern may also result from the relatively high certainty about their epidemiology and pathology; also these pathogens do not pose an immediate danger to the material interests of industrialised states. Furthermore, HIV/AIDS, malaria, and TB do not threaten the global ‘jet set’, and are therefore perceived as diseases of the poor by global elites, which in turn results in the continuing lack of effective response (see Farmer 2003; Poku 2002). Moreover, examination of the success of various countries in controlling the epidemic demonstrates that a state with high capacity (such as Canada) had a much more difficult time in containing the infection than did states with lower capacity, particularly Vietnam. Recent epidemiological evidence suggests that SARS appears to thrive under conditions that promote nosocomial transmission (SARS Commission 2006). Therefore, the sealed hospitals of developed societies appeared to facilitate SARS transmission through internalised ventilation systems. Conversely, Vietnamese hospitals are often open air, diminishing the probability of nosocomial transmission. In other words, the SARS coronavirus appears to be more transmissible in the sealed hospital and urban environments of high-capacity nations. Ironically, then, SARS would seem to pose a greater threat to states of higher capacity. In early 2006 the consolidation of global public goods, such as improved pathogen surveillance systems, and pathogenic containment regimes resulted from two central factors, namely fear and the attendant economic loss generated by contagion. A significant amount of leadership to provide such public goods has, in fact, been provided by hegemonic pressures (i.e., the U.S.), with the assistance of many other developed countries in order to shore up surveillance and containment capacity within the developing world. This issue of regional and national capacity will continue to affect the dynamics of global health governance (Price-Smith 2002a). SARS emerged in the Pacific Rim states, which exhibit moderate to high capacity, wherein NGOs and private citizens (e.g., physicians) possessed the technical means both to acquire public health data and then to disseminate it on a global scale via high-tech communications. However, in the poorer regions of the developing world where endogenous human capital levels are rather limited, where the communications infrastructure is meagre or non-existent, and where NGOs may have a difficult time in gaining access to certain areas, collaborative public health governance will remain

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extremely problematic. For example, the power of sovereign states over domestic health governance issues concerning HIV/AIDS and malaria appears to remain largely intact. Data on the true state of HIV prevalence are leaking out to the global community through NGOs, but affected sovereign states (e.g., Zimbabwe, South Africa) have been extremely reluctant to bow to the wishes of the WHO or the international community in their handling of the HIV/AIDS pandemic. In the final analysis, the emergence and proliferation of infectious agents will logically increase as processes of globalisation accelerate; however, disease events will act as biotic countermeasures (negative feedback loops) to slow such processes of globalisation through reductions in the movement of trade goods and migrants, depletion of human capital, and constraints upon economic productivity.14 In a very real sense, then, disease acts as a negative feedback mechanism on such processes of globalisation. The optimal way to diminish the negative effects of disease on globalisation is through the following: reduce the degradation of natural environments, which slows processes of zoonotic transference; implement redistributive mechanisms to improve the basic health of the human species, particularly in the least developed countries; and construct and maintain global public health surveillance systems. The proliferation of avian influenza, particularly the H5N1 strain, from East Asia to Africa and Europe, and the significant concern it has generated suggest that political elites have begun to grasp the consequences of emerging infections for prosperity, global governance, and even national security. One can only hope that lessons gleaned from the SARS epidemic (such as increased transparency, greater intergovernmental cooperation, and investments in public health infrastructure) will be employed in the event of a pandemic influenza. Nations that choose to ignore the warning of the SARS epidemic do so at their peril.

Recommendations The optimal means to curtail future epidemics (and pandemics) is to augment the endogenous capacity of healthcare infrastructure and improve the basic health of populations throughout the developing world. This makes logical sense because disease-surveillance capacity in many developing areas is low to nonexistent. Barry Bloom (2003) argues that ‘in a world that is increasingly angry at the United States, the lesson here is that it is time to support a global war on disease. The United States should be investing efforts and funds to strengthen the health structures in countries around the world … This investment would protect our country and every other against global epidemics, save millions of lives, and change the U.S. image from one of self-interest to one of human interest.’ Julie Gerberding (2003), head of the U.S. Centers for Disease Control and Prevention, echoes these sentiments: ‘The SARS experience reinforces the need to strengthen global surveillance, to have prompt reporting, and to have this reporting linked to adequate and sophisticated diagnostic laboratory capacity. It underscores the need for strong global public health systems, robust health service infrastructures, and expertise that can be mobilized quickly

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across national boundaries to mirror disease movements.’ Such assistance in the domain of public health could significantly enhance the U.S.’s tarnished international image and augment the diminished levels of soft power (Nye 2002). The health of developed countries is increasingly affected by microbes emerging in the poorer reaches of the developing world (e.g., avian influenza, West Nile virus, SARS). Therefore, global public health can be understood as a public good, and the costs of epidemiological surveillance and containment should be borne by the international community, although continued diplomatic leadership by the hegemon (the U.S.) will doubtless be central. Furthermore, where possible, states should possess (or develop) a level of surge capacity to deal with epidemic events that generate mass morbidity and mortality. At present there is little surge capacity within the U.S. as a result of its uniquely market-driven healthcare system. Notes 1 On environmental degradation, see Price-Smith (2002a, 141–170); on trade and tourism, see Davis and Kimball (2001); on conflict, see Elbe (2002) and Ostergard (2002); and on the distribution of resources see Poku (2002) and Farmer (2003). 2 For a discussion of the adverse effects of affect (specifically fear) in decision making see Jervis (2005, 1–32). 3 On republican theory in international relations see, in particular, Deudney (2007); for a republican reformulation of realist theory see Price-Smith (2008). 4 A ‘society of states’ cooperating in this regard is the optimal way to generate global public goods such as surveillance and containment; see Bull (1995); Smith, Beaglehole, Woodward et al. (2005), and Kaul, Conceição, Le Goulven, et al. (2003). 5 On the subject of PE theory see Gould (2002, 765–768). 6 On such non-linear dynamics see Tainter (1986). 7 An example of this phenomenon is the dramatic effects on international relations resulting from World War II, which saw the formation of the entire UN system and its attendant international organisations. World War II also generated responses within Europe leading to the European Coal and Steel Community and ultimately to the emergence of the European Union as a supranational entity. 8 For a comprehensive definition of state capacity see Price-Smith (2002a). 9 Jian kang bao (Health News), 7 July 2003, p. 5. 10 Renmin ribao (People’s Daily), 14 April 2003, p. 1. 11 For more on state capacity, see Price-Smith (2002a). 12 Renmin ribao (People’s Daily), 24 November 2003. 13 Renmin ribao (People’s Daily), 30 April 2003, p. 1. 14 For a discussion of bio-social negative feedback loops see Jervis (1997, 134–135).

References Asian Development Bank (2003). ‘Assessing the Impact and Cost of SARS in Developing Asia.’ In Asian Development Outlook 2003 (Oxford: Oxford University Press) <www.adb. org/Documents/Books/ADO/2003/Update/sars.pdf> (September 2008).

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Association of South East Asian Nations (2003). ‘Joint Declaration: Special ASEAN Leaders Meeting on Severe Acute Respiratory Syndrome.’ 29 April. Bangkok. <www.aseansec. org/14750.htm> (September 2008). Bloom, Barry R. (2003). ‘Lessons from SARS.’ Science, vol. 300, no. 5620, p. 701. <www. sciencemag.org/cgi/content/summary/300/5620/701> (September 2008). Blyth, Mark (2002). Great Transformations: Economic Ideas and Institutional Change in the Twentieth Century. (New York: Cambridge University Press). Bradscher, Keith and Lawrence K. Altman (2003). ‘Isolation, an Old Medical Tool, Has SARS Fading.’ New York Times, 21 June, p. 1. Bull, Hedley (1995). The Anarchical Society: A Study of Order in World Politics. (New York: Columbia University Press). Chan, Cecilia L.W. (2003). ‘The Social Impact of SARS: Sustainable Action for Rejuvenation of Society.’ Centre on Behavioural Health, University of Hong Kong, Hong Kong. <web.hku.hk/~bhealth/Documents/articles/YPSY0006/Social_Impacts_of_SARS.pdf> (September 2008). China. National Bureau of Statistics (2002). China Statistical Yearbook. (Beijing: China Statistics Press). Ching Cheong (2003). ‘Chinese PM’s Tacit Apology.’ Straits Times, 1 May. Crampton, Thomas (2003). ‘Strategy Set to Isolate Virus: Key Asia Leaders Map SARS Steps.’ International Herald Tribune, 1 May. <www.iht.com/articles/2003/05/01/sars. php> (September 2008). Crosby, Alfred (1986). Ecological Imperialism: The Biological Expansion of Europe. (Cambridge: Cambridge University Press). Curley, Melissa and Nicholas Thomas (2004). ‘Human Security and Public Health in Southeast Asia: The SARS Outbreak.’ Australian Journal of International Affairs, vol. 58, no. 1, pp. 17–32. Davis, Robert and Ann Marie Kimball (2001). ‘The Economics of Emerging Infections in the Asia-Pacific Region.’ In A. Price-Smith, ed., Plagues and Politics: Infectious Disease and International Policy, pp. 59–75 (New York: Palgrave). Deudney, Daniel (2007). Bounding Power: Republican Security Theory from the Polis to the Global Village. (Princeton: Princeton University Press). Diamond, Jared (2005). Guns, Germs, and Steel: The Fates of Human Societies. (New York: W.W. Norton). Diehl, Paul and Gary Goertz (2000). War and Peace in International Rivalry. (Ann Arbor: University of Michigan Press). Elbe, Stefan (2002). ‘HIV/AIDS and the Changing Landscape of War in Africa.’ International Security, vol. 27, no. 2, pp. 159–177. Embassy of Switzerland (2003). ‘China Business Briefing.’ 12–18 May, No. 140. Beijing. <www.sinoptic.ch/cbb/2003/cbb030512-030518.htm> (September 2008). Farmer, Paul (2003). Pathologies of Power: Health, Human Rights, and the New War on the Poor. (Berkeley: University of California Press). Fei Feng (2006). ‘The Development of China’s Manufacturing Sector and Its International Competitiveness.’ Gaige, 12 October. <articles.e-works.net.cn/Articles/444/Article41009. htm> (September 2008). Fidler, David P. (2004). SARS: Governance and the Globalization of Disease. (New York: Palgrave Macmillan). ‘GDP Growth Revised Up for 1st Half of 2003.’ (2004). China Daily, 20 July. <www. chinadaily.com.cn/english/doc/2004-07/20/content_349887.htm> (September 2008).

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Gerberding, Julie L. (2003). ‘CDC Response to Severe Acute Respiratory Syndrome (SARS).’ Testimony before the Committee on Health, Education, Labor, and Pensions, United States Senate. United States Department of Health and Human Services, Washington DC. <www. hhs.gov/asl/testify/t030429_a.html> (September 2008). Gould, Stephen Jay (2002). The Structure of Evolutionary Theory. (Cambridge MA: Harvard University Press). Haas, Ernst B. (1964). Beyond the Nation-State: Functionalism and International Organization. (Stanford: Stanford University Press). Hirschman, Albert O. (1991). The Rhetoric of Reaction: Perversity, Futility, Jeopardy. (Cambridge MA: Belknap Press). Homer-Dixon, Thomas (2001). The Ingenuity Gap: Can We Solve the Problems of the Future? (Toronto: Vintage). Hu Angang and Hu Linlin (2004). ‘A Review of China’s Health and Development from the Perspective of SARS.’ Center for Strategic and International Studies, Washington DC. <www.csis.org/media/csis/events/040218_angang.pdf> (September 2008). Huang, Yanzhong (2003). Mortal Peril: Public Health in China and Its Security Implications. Health and Security Series Special Report No. 7. Chemical and Biological Arms Control Institute, Washington DC. Jervis, Robert (1997). System Effects: Complexity in Political and Social Life. (Princeton: Princeton University Press). Jervis, Robert (2005). American Foreign Policy in a New Era. (New York: Routledge). Johnson, Niall and Juergen Mueller (2002). ‘Updating the Accounts: Global Mortality of the 1918–1920 Spanish Influenza Pandemic.’ Bulletin of the History of Medicine, vol. 76, no. 1, pp. 105–115. Kaul, Inge, Pedro Conceição, Katell Le Goulven, et al., eds. (2003). Providing Global Public Goods: Managing Globalization. (New York: Oxford University Press). Krasner, Stephen D. (1984). ‘Approaches to the State: Alternative Conceptions and Historical Dynamics.’ Comparative Politics, vol. 16, no. 2, pp. 223–246. Little, Bruce (2004). ‘Was There a Recession in Ontario?’ Globe and Mail, 27 January, p. B4. McNeill, William (1977). Plagues and Peoples. Updated ed. (New York: Anchor Books). Morse, Stephen S. (2001). ‘Factors in the Emergence of Infectious Diseases.’ In A. PriceSmith, ed., Plagues and Politics: Infectious Disease and International Policy, pp. 8–26 (New York: Palgrave). National Advisory Committee on SARS and Public Health (2003). Learning from SARS: Renewal of Public Health in Canada. Chaired by David Naylor. Ottawa. <www.phac-aspc. gc.ca/publicat/sars-sras/naylor> (September 2008). Nye, Joseph S. (2002). The Paradox of American Power: Why the World’s Only Superpower Can’t Go It Alone. (New York: Oxford University Press). ‘Officials Need to Stay on Top of Rumour Mill.’ (2003). South China Morning Post, 12 February. Ostergard, Robert (2002). ‘Politics in the Hot Zone: AIDS and the Threat to Africa’s Security.’ Third World Quarterly, vol. 23, no. 2, pp. 333–350. Peiris, J.S., S.T. Lai, L.L. Poon, et al. (2003). ‘Coronavirus as a Possible Cause of Severe Acute Respiratory Syndrome.’ Lancet, vol. 361, no. 9366, pp. 1319–1325. Peterson, Susan (2002). ‘Epidemic Disease and National Security.’ Security Studies, vol. 12, no. 2, pp. 42–81. Pirages, Dennis (1996). Microsecurity: Disease Organisms and Human Well-Being. Environmental Change and Security Project Report No. 2. Woodrow Wilson International

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Centre for Scholars, Washington DC. <www.wilsoncenter.org/topics/pubs/ACFA6.pdf> (September 2008). Poku, Nana K (2002). ‘Poverty, Debt, and Africa’s HIV/AIDS Crisis.’ International Affairs, vol. 78, no. 3, pp. 531–546. Pomfret, John (2003a). ‘Underreporting, Secrecy Fuel SARS in Beijing, WHO Says.’ Washington Post, 17 April, p. A16. Pomfret, John (2003b). ‘Official Says China Erred on Outbreak; Rare Apology Cites “Poor Coordination”.’ Washington Post, 5 April, p. A14. Pomfret, John (2003c). ‘Doctor Says Health Ministry Lied about Disease.’ Washington Post, 10 April, p. A26. Porter, Catherine (2004). ‘SARS Toll on Film Industry: $163 Million.’ Toronto Star, 9 March, p. B3. Prescott, Elizabeth M. (2003). ‘SARS: A Warning.’ Survival, vol. 45, no. 3, p. 211. Price-Smith, Andrew (1999). ‘Ghosts of Kigali: Infectious Disease and Global Stability at the Turn of the Century.’ International Journal, vol. 54, no. 3, pp. 426–442. Price-Smith, Andrew (2002a). The Health of Nations: Infectious Disease, Environmental Change, and Their Effects on National Security and Development. (Cambridge MA: MIT Press). Price-Smith, Andrew (2002b). Pretoria’s Shadow: The HIV/AIDS Pandemic and National Security in South Africa. (Washington DC: Chemical and Biological Arms Control Institute). Price-Smith, Andrew (2008). Contagion and Chaos: Disease, Ecology, and National Security in the Era of Globalization. (Cambridge MA: MIT Press). Price-Smith, Andrew and John L. Daley (2004). Downward Spiral: HIV/AIDS, State Capacity, and Political Conflict in Zimbabwe. (Washington DC: United States Institute of Peace Press). SARS Commission (2006). Spring of Fear. Report of the commission chaired by Archie Campbell. Ontario Ministry of Health, Toronto. <www.health.gov.on.ca/english/public/ pub/ministry_reports/campbell06/campbell06.html> (September 2008). Saywell, Trish, Geoffrey A. Fowler, and Shawn W. Crispin (2003). ‘The Cost of SARS: $11 Billion and Rising.’ Far Eastern Economic Review, 24 April. Schumpeter, Joseph A. (2005). Capitalism, Socialism, and Democracy. (New York: Routledge). Singer, Peter W. (2002). ‘AIDS and International Security.’ Survival, vol. 44, no. 1, pp. 145–158. Skocpol, Theda (1985). ‘Bringing the State Back In: Strategies of Analysis in Current Research.’ In P. Evans, D. Reuschemeyer, and T. Skocpol, eds., Bringing the State Back In (New York: Cambridge University Press). Smith, Richard, Robert Beaglehole, David Woodward, et al. (2005). Global Public Goods for Health: Health, Economics, and Public Perspectives. (Oxford: Oxford University Press). Spears, John (2003). ‘SARS Impact Lingers with Lost Tourism Spending Estimated Near $1 Billion.’ Canadian Press, 14 October. Tainter, Joseph (1986). The Collapse of Complex Societies. (Cambridge: Cambridge University Press). Taubenberger, Jeffery K. and David M. Morens (2006). ‘1918 Influenza: The Mother of All Pandemics.’ Emerging Infectious Diseases, vol. 12, no. 1. <www.cdc.gov/ncidod/EID/ vol12no01/05-0979.htm> (September 2008). ‘The SARS Outbreak—Interview: Goh Chock Tong, Leading the Charge against SARS.’ (2003). Far Eastern Economic Review, 8 May.

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United States National Intelligence Council (2000). The Global Infectious Disease Threat and Its Implications for the United States. National Intelligence Council, Washington DC. <www.dni.gov/nic/PDF_GIF_otherprod/infectiousdisease/infectiousdiseases.pdf> (September 2008). Vatikiotis, Michael (2003). ‘The Sars Outbreak: ASEAN and China—United in Adversity.’ Far Eastern Economic Review, 8 May. World Health Organization (2003a). ‘Summary Table of SARS Cases by Country, 1 November 2002 – 7 August 2003.’ 15 August. Geneva. <www.who.int/csr/sars/country/2003_08_15/ en> (September 2008). World Health Organization (2003b). ‘Revision of the International Health Regulations.’ WHA65.28. Resolution of the World Health Assembly, 28 May. Geneva. <www.who.int/ gb/ebwha/pdf_files/WHA56/ea56r28.pdf> (September 2008). World Health Organization (2003c). ‘Update 95—SARS: Chronology of a Serial Killer.’ Geneva. <www.who.int/csr/don/2003_07_04/en> (September 2008). World Health Organization (2003d). ‘Summary of Probable SARS Cases with Onset of Illness from 1 November 2002 to 31 July 2003.’ Geneva. <www.who.int/csr/sars/country/ table2004_04_21/en> (September 2008). Zartman, I. William (1995). Collapsed States: The Disintegration and Restoration of Legitimate Authority. (Boulder CO: Lynn Rienner).

Chapter 3

Lessons from SARS: Past Practice, Future Innovation Carolyn Bennett

We are not tinkers who merely patch and mend what is broken … We must be watchmen, guardians of the life and health of our generation, so that stronger and more able generations may come after. —Elizabeth Blackwell In 1849, Elizabeth Blackwell, M.D.—the first woman to graduate from medical school in the United States—made some compelling observations about the importance of population health. She was not the first, however, to express a memorable sentiment of this kind. More than four millennia earlier, Shi Huangdi, China’s Yellow Emperor, outlined the importance of keeping a population healthy when he said that ‘to administer medicines to diseases which have already developed … is comparable to the behaviour of those persons who begin to dig a well after they have become thirsty, and of those who begin to cast weapons after they have already engaged in battle’. Although simplistic, these logical principles remain an ongoing challenge, integral to the foundation and growth of the Canadian healthcare system. Tommy Douglas (1984), one of the founders of universal health care in Canada in the 1960s, emphasised the importance of disease prevention and health promotion and believed that the primary objective ‘must be to keep people well rather than just patching them up when they got sick’. The emphasis on this task was underscored by Marc Lalonde (1974), Canada’s minister of health and welfare from 1972 to 1977, in a report entitled A New Perspective on the Health of Canadians: A Working Document. Laying out two objectives (reducing health risk and improving access to care), Lalonde proposed five strategies for health: promotion, regulation, research, system efficiency, and goal setting. These strategies have remained integral to Canada’s health plan ever since. With the Lalonde report, Canada led the world in the development of a population health approach. Since then, poverty, violence, the environment, education, shelter, and equity are known to be as important to the health of Canadians as the ‘sickness’ care system. This consideration of population health was again reflected in the development of the Ottawa Charter for Health Promotion, adopted by the International Conference on Health Promotion in 1986, which broadly defines health promotion as the ‘process of enabling people to increase control over, and to improve, their health’ (World Health Organization [WHO] 1986). In short, the

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simple statements of Dr. Blackwell and Shi Huangdi have presided over Canadian healthcare history. In the current post–September 11 atmosphere and post–severe acute respiratory syndrome (SARS) environment, one cannot underestimate the imperative of dealing aggressively with all determinants of health. Not surprisingly, Canada’s health goals have continued to evolve as new challenges differentiate the current global environment from its past. Those goals are different in terms of understanding one’s responsibility to the world—to make the world a healthy place for all people through leadership, collaboration, and knowledge. This chapter explores the importance of the SARS pandemic as a catalyst in this shift. Its observations are largely informed by my role as Canada’s first minister of state for public health, from 2003 to 2005, and by my subsequent experience, including participating in Global Pandemic Influenza Readiness, an international conference of health ministers from 30 countries and representatives from nine international organizations in 2005. With this experience as a backdrop, this chapter examines the way in which the encounter with SARS prompted Canada to take a leadership position in pandemic preparedness as well as the way in which this type of preparedness improves public health infrastructure in the world—in surveillance, capacity, and all of the elements that will make this a healthier planet. The by-product of preparing for a pandemic is the forced re-evaluation of existing systems and a focus on the necessity of a proper public health infrastructure around the globe. For western countries, which have recaptured an interest in public health, this has been immensely important. The focus on Douglas’s original views of medicare—keeping people healthy rather than patching them up—seems to have been blurred in favour of a sickness care system and a dependence on the development of miracle drugs that will cure all ails. In this respect, our health objectives have faltered in the ‘tyranny of the acute’. As David Naylor points out, examples of actual and potential harm to the health of Canadians from weaknesses in public health infrastructure have been mounting for years without a truly comprehensive and multi-level governmental response (National Advisory Committee on SARS and Public Health [Naylor report] 2003). As a wake-up call, the upstream reality of what Canada learned from the Walkerton experience, where seven people died as a result of E. coli contamination of the public water supply in 2000, and what should have been learned from HIV/AIDS, sounded in concert with the SARS experience. The call served as a reminder that there is a serious need for global governance on health. Canada’s response can be considered in the context of the impact of SARS on Toronto, the lessons learned from the experience of Toronto’s fellow cities of Hong Kong, Hanoi, and Bangkok, and the hope and encouragement experienced at the 2005 health ministers conference in Ottawa. However, it is important first to establish the lenses through which this examination will be viewed. First, Ursula Franklin provides an overarching perspective on governance, in particular, her decree that governance must be fair, transparent, and take people

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seriously. If this is not enforced in small organisations, then there is little hope in managing any national or global undertaking. Second, my position as minister responsible for the Public Health Agency of Canada (PHAC) provided an exceptional opportunity to take those activities that had been conducted within a government department and move them to an arm’s-length agency, with independent thinking and an opportunity to work with the provinces and territories in order to transform public health in Canada. This agency relies on real, scientifically based evidence, with a declaration to support what works to produce that evidence. Third, tied closely to Franklin’s observations on governance, is meaningful citizen engagement. It is important to be connected to human responses and to know what people are frightened of—because that is what actually changes behaviour. The public must be put back into public health. In the interest of transparency, it is important to declare that global health governance is relatively new to me. My ideology is primarily bottom up and, consequently, the task of describing what governance should look like has not come naturally in the past. However, the complexity theory, distributive models, and the adaptive principles explored in a discussion paper by Sholom Glouberman and Brenda Zimmerman (2002) for the Commission on the Future of Health Care in Canada is reminiscent of—and well complemented by—the oft-repeated H.L. Mencken quote: ‘There is always an easy solution to every human problem—neat, plausible, and wrong.’ It is imperative for both health authorities and engaged citizens to keep this in mind while conceiving the health goals for Canada’s future. Glouberman and Zimmermann (2002) highlight the differences between the responses of Brazil and African countries to HIV/AIDS. They identify Brazil’s response to a prediction by the World Bank that the country did not have sufficient resources to resist HIV infection. The events that took place in Brazil were unprecedented and, certainly, unpredictable. In spite of the harsh statements from the World Bank, the Brazilian people organised themselves in a way that no one could have predicted.1 Brazilians were not going to let a generation die off and decided not to do as they were told. Doctors and civilians managed to attain drugs and drew circles on pieces of paper to explain to people what time of day to take them; nuns and priests handed out condoms. From the bottom up, Brazilians were able to organise in a way that meant the incidence of HIV/AIDS in their country declined, while in much of Africa it went through the roof. The Brazilian experience is an impressive display of the capacity of selfmotivated citizens on the ground. In light of this type of bottom-up approach, the exploration of health governance herein is framed by the fact that one cannot impede or underestimate what communities are capable of if they are just asked. The familiar Hollywood portrayal of scientists wandering around in white lab coats and fixing everything for people is neither realistic nor feasible as a public health strategy. In this respect, the medical myth is getting in the way of what it will take for communities to find out what they need and for them to be able to ask for help

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in a way that must be respected. This, of course, became all too clear in the case of SARS.

From Tinkers to Guardians: The Effect of Canada’s Experience at Home SARS dramatically reinforced the inescapable reality of Marshall McLuhan’s 1964 characterisation of this world as a global village (National Advisory Committee 2003). It became very clear that germs do not respect borders. In this village, Canada was affected more severely than any other country in the western hemisphere. A total of 438 people became infected (Health Canada 2008); 44 of them died, including three healthcare workers. The response to the outbreak paralysed a major segment of Ontario’s healthcare system for weeks and resulted in more than 25 000 residents of the greater Toronto area being placed in quarantine. The psychosocial effects of SARS on healthcare workers, patients, and families continue to be assessed even today. However, this is only the acute human face of SARS. The overall impact extended further. When the World Health Organization (WHO) warned against unnecessary travel to Toronto in April 2003, visits to the city plummeted and rock concerts, sporting events, movie shoots, and conventions were cancelled or relocated. As the Naylor report identified, the estimates, based on the volume of business compared to usual seasonal activities, suggested that tourism sustained a loss of CA$350 million, the reduction in airport activity cost CA$220 million, and non-tourism retail sales were down by CA$380 million in 2003 (National Advisory Committee 2003, 211). Ultimately, direct and indirect costs in Ontario added up to more than CA$2 billion in revenues and tourism jobs, and the number of non-residents entering the country fell by 13 percent, affecting tourism throughout the country. For example, the province of Quebec was affected, despite not having a single reported case of SARS. The SARS experience in Canada was a failure of both communication and science. Primarily, the authorities did not know what they needed to know and therefore could not pass on crucial information. What was the mode of transmission? No one knew. What was the incubation period? No one knew. And—significantly— how could authorities reassure people, or explain what they did not know—namely, that it was a hospital-based disease spread by intimate contact? No one knew. In short, it was a tremendous failure in terms of what David Naylor later called the four C’s: collaboration, cooperation, communication, and the clarity of who does what when. As a result of this failure, the authorities were forced to re-evaluate their ability to share information within a complex federal system—across different levels of government and among hospitals, healthcare providers, and local public health offices, and even across provincial borders. In some cases, it was reported that data sets would not be shared because it was not clear who would be the principal investigator for that particular study. In other cases, the data were unclear whether infection started with one patient who went to two hospitals or two patients who went

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to two hospitals. Canadian health officials had insufficient trusted data and therefore were, rightfully, embarrassed. Inefficiencies and arguments over less pressing issues, including doctors and nurses crossing borders, ultimately, obstructed productive aid. Places with regional health authorities, such as British Columbia, seemed to perform better than the local health authorities did in Ontario. Singapore also did very well in terms of the magnitude of people affected and was able to get a few things right. There, health authorities designated one hospital to take care of all SARS patients. That institution provided a seamless liaison with public health operations. Authorities were able to trace all patients’ contacts within 24 hours of each admission, and the minister of health was the spokesperson. He held regular daily press briefings and shared the facts, uncertainties, and potential worst-case scenarios with the public, as well as provided concrete suggestions of how Singaporeans could protect themselves. In Canada, by contrast, there were multiple sites and rotating public health officials, clinicians, and politicians all appearing at different times and delivering mixed messages. Admittedly, a city-state such as Singapore offers some advantages regarding the centralisation of decision making that Canada’s multi-layered system does not offer. Nevertheless, in an emergency situation, it is necessary that Canadian municipal, provincial, and federal governments speak with one voice and be clear about who is responsible for what. It is unacceptable that in Canada—a country that has developed leading technology in mobile communication—healthcare authorities and citizens were not better able to communicate with individual physicians or front-line workers. These are the issues that should remain a concern for the public, and changes have been made in this regard. Licensing boards in all provinces and territories now require physicians to supply their contact information in case of an emergency, which is certainly a preliminary improvement in terms of communication. More generally, since 2001 initiatives have focussed on restructuring the communication channels among federal and provincial governments, the media, and the public. Federal communications were generally reactive (as Health Canada waited for the latest press conference in Ontario); in turn, provincial communications were frequently disorganised, and crisis communication to the public was similarly unacceptable. Consequently, the National Advisory Committee on SARS and Public Health immediately proposed a number of changes in the collaboration between the federal, provincial, and territorial levels of government and the media, including the possibility of a comprehensive training programme for crisis communication similar to that designed by the Centers for Disease Control and Prevention (CDC) in the United States (National Advisory Committee 2003).� Although some progress has been made in Canada, there remains a dire need to improve two-way accountability—the kind of communication that allows people to report and receive the type of data that, during the SARS crisis, was changing three times a day. Throughout that period, health authorities were continually reassessing whether the mode of virus transmission or the incubation period or the other essential factors were changing, yet the dissemination of up-to-the-minute

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information proved to be a challenge in certain parts of the country, given the existing communications infrastructure. Graphing total cases per day instead of new cases provided an alarming picture on the Health Canada website. The experience was a chilling wake-up call, and Canada is now better prepared. However, there is still much more work to do. SARS has taught the lesson that the luxury of a central command-and-control approach is not a possibility in Canada. Unlike the experience of Singapore, where all SARS cases could be seen at a single facility, even the containment of SARS within the Greater Toronto Area did not necessarily lend itself to the Singapore model given the unique conditions there, such as culture and health systems. When new information is emerging continually from the trenches, authorities must be able to interpret it. The question remains, however, how to take new information and allow the front-line responders in each area to do what they know to be best in their community or for their population base. They know whom to call. They know the infrastructure. They know who their potential partners are. How can authorities ensure, in terms of crisis governance, that local workers are not impeded from doing what they really know how to do? In essence, these issues force the realisation that the largest obstacle to managing a public health crisis successfully is a lack of a collaborative framework and ethos among different levels of government, health authorities, citizens, and practitioners. Canada has taken the lessons learned from SARS into a broader context: pandemic preparedness both at home and in the global village. David Naylor’s thoughtful report was, in fact, a blueprint of what needed to be done in this country (National Advisory Committee 2003). As the minister of state for public health my department established the PHAC and appointed the first chief public health officer, David Butler-Jones. He was then able to nurture and develop cooperation and collaboration among medical officers of health for all 13 provincial and territorial jurisdictions in the country into PHAC, so that public health could be conceived as an inclusive collective. The creation of PHAC and the position of chief public health officer of Canada allowed the deputy head of an agency—for the first time in Canadian history—to speak directly to Canadians to deliver science-based advice, rather than go through political channels. There were immediate changes within the Ontario’s Ministry of Health as well. For example, as part of an internal reorganisation, an office was established to coordinate the development of an emergency preparedness programme, integrate it into planning, identify the infrastructure requirements for its maintenance, and develop a quality improvement programme. Since its inception, this office has created a number of programmes addressing issues in emergency planning and preparedness for citizens and healthcare providers, with specific concern for influenza pandemic planning and avian influenza. Ultimately, the SARS experience reinforced the case for a collaborative and coordinated approach to public health, making it evident that systems-based thinking and coordination within a welldesigned infrastructure are as essential in a crisis as they are in the core functions of public health (212).

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Casting Weapons: Canada in the Global Village In tandem with these domestic improvements, Canada’s global public health position has also improved in its overall framework. The emergency operation centres in Ottawa and Winnipeg are linked to the provinces and territories, the U.S. Department of Health and Human Services, the CDC, and the WHO. Canadian health authorities have activated these systems several times in recent years, both in the table-top exercises with the United Kingdom and the United States and in Canada’s role as chair of the Global Health Security Action Group (GHSAG), a strong indication of Canada’s improved global health position. The GHSAG was established to improve public health security against chemical, biological, or radio-nuclear terrorism as well as pandemic influenza. It includes the G7 countries, Mexico, the European Commission, and the WHO. Moreover, Canada has become the first country to negotiate a ten-year contract (beginning in 2001) with a domestic manufacturer capable of providing a pandemic vaccine for the entire Canadian population as soon as the organism is identified, should the need arise. Canadian health authorities have created a national antiviral stockpile and committed to the production and testing of a prototype of H5N1 vaccine that will increase capacity and knowledge of the efficiency of a vaccine against this strain of avian influenza, or one that is similar. Furthermore, Canada has expanded the Quarantine Act, extending the government’s legislative authority to screen, examine, and detain arriving and departing travellers and conveyances (such as airplanes or cruise ships), including their goods and cargo, that may be a public health risk to Canadians and people world-wide. The act also includes contemporary public health measures, such as ordering treatments or other preventive measures. However, as encouraging as these measures are, Canada cannot simply shut its borders to a pandemic. If, for example, the disease renders an individual infectious for days before symptoms show, it is not possible to contain all pathogens completely given the availability of 24-hour flights from across the world. This was made painfully obvious when, in 2007, air travellers were possibly exposed to a contagious form of tuberculosis when Andrew Speaker, infected with a drug-resistant strain of the disease, flew from Paris to Atlanta by way of Prague and Montreal. In preparing for pandemics, it is important to understand that information changes so often that plans must be consistently and constantly revised. The focus may be on a bird virus, but a pandemic could originate from swine or some other animal influenza. No one knows what the source of the next one will be, but we know there will be one, someday. Pandemic preparedness plans should possess the elasticity to account for different pathogenic sources. The situation may be likened to life in an earthquake zone. Someone who purchases a condo in Vancouver, for example, will want to ensure that the building was constructed in conformity to the appropriate building code and that the City of Vancouver has sufficient rescue vehicles and an effective earthquake plan with appropriate resources, because that individual will be aware that Vancouver is in an earthquake zone. However, despite these precautions,

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one can assume that there will be unforeseen circumstances that will fall outside the plan. The same assumption applies when considering a pandemic. There is no question that it was easier to plan for the Y2K, because everybody knew they had until 31 December 1999 to put the plan in place. People could determine a critical path with their partners in business, labour, government, and nongovernmental organisations (NGOs). Work could be performed with a deadline in mind, without people’s sense of purpose flagging. The concept of emergency preparedness is different. The whole point of emergency preparedness is to have plans in place in case an unfortunate event occurs—but that event might not happen, or it might happen at some moment in the distant, unknowable future. Unfortunately, as with earthquakes, this is the reality with regard to viruses and bioterrorism. Another challenge facing Canada is that many countries are not preparing at all, and others simply do not have the capacity to prepare without Canadian aid. The WHO and Canada, together and collaboratively with other countries, have been trying to work with those countries that are currently most at risk. For example, in 2005 Vietnam sent officials and scientists to Winnipeg to learn how to build their own laboratory capacity at home. Canada invested CA$15 million in the CanadaAsia Regional Emerging Infectious Disease Initiative, in order to help build public health capacity and surveillance in southeast Asia. Some countries, regrettably, lack candour or transparency with regard to admitting the existence and severity of a problem. Working with the WHO, Canada invented the Global Public Health Intelligence Network (GPHIN), which combs the internet for media releases and newspaper clippings in seven languages for any potential health hazard (Zacher 2007, 19; PHAC 2004). The International Health Regulations (IHR) issued by the WHO are legally binding regulations adopted by most countries to contain the threats from diseases that may rapidly spread from one country to another. Such diseases include emerging infections like SARS or a new human influenza virus. The revised IHR issued in 2005 are a great improvement over their predecessor and bring disease control into the 21st century (WHO 2006). Updated to prevent, protect against, and control the international spread of disease, they provide a public health response when disease does spread internationally. However commendable, the effectiveness of these regulations depends on each country’s capacity to identify, verify, and manage critical outbreaks. When the quality of data is challenged, as has been the case in various countries, the effectiveness of the IHR becomes an issue. In other words, there are some pieces in place but no system is perfect. Many countries have trouble simply reporting their births and deaths accurately, which calls into question their ability to manage information about an outbreak. By 2003, Hong Kong had already developed various ideas and responses regarding pandemic preparedness because of its experience with the H5N1 strain since 1997. For example, in the market, unsold birds did not return home to the farm: any bird that was not sold was killed and eaten, so there was no traffic from the marketplace to the farm. Health authorities found a vaccine that had worked for another virus that had some impact on the avian influenza virus.

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Reacting to Vietnam’s experience with avian influenza, officials from the World Bank, the Food and Agriculture Organization (FAO), the Asian Development Bank (ADB), the Joint United Nations Programme on HIV/AIDS (UNAIDS), the United Nations Development Programme (UNDP), and the WHO met in Hanoi for extensive discussions about funding health systems and providing compensation for culled birds. Subsequently, various NGOs such as Vétérinaires Sans Frontières and Save the Children met. The differences between the discussion with the international organisations and the discussion with NGOs with first-hand experience in the trenches—working every day with the citizens in the communities in Vietnam—were plentiful. The activity on the ground at Thailand’s Mahidol University was fascinating in terms of bottom-up realities, surveillance, and capacity building. Their X-ray surveillance system was most impressive. In fact, Thailand’s approach was commonly referred to at the international conference of health ministers in Ottawa in 2005. Every community in Thailand identified, using a sociogram, the health volunteer for that community, who then received appropriate training. That individual was the most trusted person to whom people could go with their secrets, from whom they would seek advice—and who could provide three days of malaria pills until they could see a health professional. That individual was the one who would go to a farmer to explain that all the chickens had to be killed. This individual would, consequently, have a huge knowledge base and would have to engage in continuous learning to improve communication systems. Canada has much to learn from countries that really do not have a highly developed healthcare system, but where keeping people well is paramount to saving lives. Michael Leavitt, U.S. secretary of health and human resources, was particularly impressed by the pandemic preparedness in southeast Asia. As the former governor of Utah, where forest fires pose a considerable problem, he appreciated the measures that had been taken in Thailand to stomp out the spark before it caught, rather than investing enormous sums of money in legions of bombers to put out the fire afterward. Canadians should expect to see all levels of government collaborate responsibly in the face of a serious threat to the health of the population. As the Naylor report says, ‘the rules and norms for a seamless public health system must be sorted out in advance of a health emergency, with a spirit of partnership and shared commitment to the health of the citizenry, not on an ad hoc basis in the midst of the battle to contain a viral outbreak’ (National Advisory Committee 2003, 212). Lessons must be learned, not only from SARS but also from what happened with previous influenza pandemics and HIV/AIDS. Again, the scenario is reminiscent of Shi Huangdi’s comments. It is not acceptable to cast weapons once we have already engaged in battle. The Global Pandemic Influenza Readiness conference in 2005 was a particularly useful opportunity for international participants to discuss key policy priorities and actions in guiding international efforts. Mainly, however, the discussions focussed on changing the mindset, admitting that no one has all the right answers, and needing to share problems, challenges and proposed solutions. As with Canada’s domestic health challenges, one of the larger impediments to dealing successfully with public

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health crises internationally was the lack of a collaborative framework and ethos— in this case among different governments and organisations. In many respects, the acceptance of the need for candour began at the conference itself, as representatives from the various countries and organisations shared their experiences openly around the table. This opportunity, to be honest, was a significant outcome in a new culture of transparency about infectious disease. The conference was organised along four main themes. The first theme, in which Prime Minister Paul Martin participated in the discussions, concerned animal– human health. It is essential to the global capacity to protect human health that the risks associated with the spread of viruses—among animals and from animals to humans—be identified early and understood well. Thus the conference participants called for increased capacity for surveillance and for the exchange of information between the agriculture and health sectors at the local, national, and international level (Health Canada 2005). They also called for the expansion and integration of the network of relevant WHO collaborating centres and the reference libraries of the FAO and the World Organisation for Animal Health (OIE) for the rapid identification of virus strains, as well as a number of other collaborative reforms. The second theme, concerning capacity and surveillance, involved discussions in which all participants celebrated the practices of the Thai government. The health ministers all recognised the need to strengthen the capacity for surveillance, the early detection and diagnosis of a range of infectious diseases, and timely communication about them as well as a rapid response. The third theme was risk communication. Canada has helped the WHO develop a manual on outbreak communication designed for the 24-hour media cycle (WHO 2005). When an alarmist statement in one part of the world could potentially affect the entire globe, it is extraordinarily important that everyone is on the same page. Finally, there was a discussion about research and access to vaccines and antiviral drugs. There was general agreement that it is imperative to push hard on the research side. The current system relies on 1950s technology for developing vaccines, which involves waiting for cultures to grow; there is a clear need for work on cellular technologies and synthetic vaccines. One must always push ahead as these viruses and bacteria have the potential to mutate. The research and development (R&D) into new forms of immunisation, as in all facets of pandemic preparedness, must be diverse and adaptive so as not to end up with all one’s eggs in one basket. In this regard, the ministers agreed to include vaccines and antivirals as key components in pandemic influenza preparedness and response plans both at the national and the international levels, to work collaboratively to advance vaccine and antiviral R&D, to develop as quickly as possible mechanisms to increase production capacity, to enhance pharmaceutical delivery so that there can be equitable access world-wide, and to call for a meeting of drug-regulating authorities to develop a framework to address common regulatory challenges in order to expedite vaccine registration and availability. Again, the issue ties into the central theme: it is integral to any health initiative that the partnerships, in terms of the key stakeholders (including civil society), play important front-line roles in preparedness planning.

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Not surprisingly, there was consensus at the conference—a firm intention to do more than simply mitigate the mortality, economic, and social outcomes of an influenza pandemic. Determining that improved surveillance, collaboration, reporting, and coordinated response will save lives long before the disease outbreaks reach the pandemic level, the ministers and officials endorsed two main principles for effective global cooperation: full transparency among countries and the institutions involved in responding to the risk of pandemic influenza and full support to the leading role of multilateral institutions. Ministers, Canadian and otherwise, approached the Ottawa meeting as an important step toward securing long-term, sustained political and institutional engagement to address global pandemic preparedness. In this respect, the weapons are being cast before the battle.

Conclusions In this brief consideration of Canada’s SARS experience and the reforms subsequently proposed in the Naylor report and then implemented, the Ottawa 2005 conference, and the birth of PHAC, it is clear that Canadians have taken lessons learned into a broader spectrum, concerning national pandemic preparedness both at home and in the global village. Domestically, the creation of a network of medical officers of health for the 13 provincial and territorial jurisdictions restructured communication among federal and provincial governments, the media, and the public, allowing public health to be conceived more inclusively as a collective effort. Most basically, the SARS experience reinforced the case for a collaborative and coordinated approach to public health, forcing Canadians to realise that ‘systems-based thinking and coordination of activity in a carefully-planned infrastructure are … integral to core functions in public health, due to its population-wide and preventive focus’ (National Advisory Committee 2003, 212). Internationally, Canada has played a substantial role as chair of the GHSAG, strengthened its relationship with the U.S. Department of Health and Human Services, the CDC, and the WHO, and made substantial improvements to the Quarantine Act. Moreover, the existence and fundamental outcome of the Ottawa conference, at which representatives from the 30 countries and 9 international organisations shared openly across the table, is another substantial indicator of Canada’s dedication to global health. The conference was a source of hope, a signal of devotion to developing a culture of transparency and collectivism. Ultimately, however, the most important conclusion to draw from the experience of SARS is that these advancements, although important, are merely steps toward securing long-term, prolonged political and institutional commitment to addressing global pandemic preparedness. Things may be better than ever, but there is still much work to do. In light of this, and with continued emphasis on communication, transparency, collaborative problem solving, and sustained engagement on the issues surrounding global health, it is appropriate to conclude by addressing some enduring problems.

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One issue that demands further attention is that of animal–human health— having vertical silos of knowledge, when there are horizontal problems, is worthy of concern. If 80 percent of new and emerging diseases come from the furry and feathery clients of the veterinarians, there needs to be a direct line of communication between public health officials and animal health workers because public health institutions must know up front what will be the future threat. In this regard, Canada has taken the lead by linking the Canadian Food Inspection Agency and the National Microbiology Laboratory in Winnipeg. This is tied to another problem, however, in regard to horizontal issues: if organisations such as the WHO only deal with health ministers, how can a whole-of-government response be possible? A second issue, related to data, again deals with a similar fault in representation and communication. If only health ministers are represented at the WHO and not the governmental departments of statistics, how can the two groups collaborate effectively to produce more trusted data? Moreover, the WHO’s disability-adjusted life year (DALY) and all those things that were not tried are not trusted anymore. What can be done with countries where even births and deaths are not recorded? How can the numerator be dealt with when the denominator is unknown? For example, a Canadian parliamentary sub-committee on people with disabilities was obliged to work with almost ten-year-old census data, which made it difficult to plan. Yet that is the norm in many countries. How can technology, such as the internet, be used to ensure that knowledge is translated for public access in real time and is rapidly disseminated, widely accessible, and scientifically reviewed? How does one ensure that citizens are initiating healthy public policy because they have received good information on the real science in a sensible way? It is sometimes much easier for citizens to pull out what is healthy public policy than it is for governments to be pushing it. People need to know how important it is to wash their hands, for example, but that information can also help change the behaviour of their healthcare providers. Once the technology issue has been resolved, publicly influenced policy making can be a very healthy step forward. Unfortunately, on top of these issues about dissemination, there are further complications with regard to research ethics. A good example is the ethical complications of working with the 1918 influenza virus, when there was no international oversight or control of the dreaded microbe. Should this work have been allowed to proceed without international approval and oversight? If not, who should have provided it? What kind of permission would be required to proceed on that kind of research? More generally, what must be done to make sure there is a normative function for a multilateral organisation, like the WHO? How should that normative function be created to ensure that the organisation sets global norms and standards and is a container of global information while at the same time relies on sound science? How should political interests be managed so that, for example, a nutrition resolution is not pushed through by the sugar-producing countries, or a life-saving measure is rejected because of a country’s religious beliefs about reproductive health?

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Governance may be firmly based on science, but the political thrust must not affect the authority of international institutions. Another closely linked fundamental issue is the determination of the mandate of organisations such as the WHO. Should they stick to reporting and standard setting in global health governance or should they have a responsibility to be on the ground, treating individuals and performing the tasks that might be done better by others? How can fairness and transparency be guaranteed? How can the accountability of a director general be assured, and how can NGOs and donors be part of the selection process of a director general? How can the funding for international organisations be made adequately stable so that, after countries have paid their annual dues, their workers do not have to spend so much of their time fundraising for the next important initiative, such as pandemic preparedness? Over time, the extraordinary socioeconomic inequities that exist among countries must become very much a part of the equation, if and when the world finally gets it right. Wealthy countries should not simply send aid cheques to poor ones, relying on geographic distance to keep them safe from the problems relayed on the nightly newscasts. In this respect, the reform of the G8 may be beneficial. The annual meeting of the most powerful economies has a large impact on the structure of the international system. Within the G8 framework, there is a distinct possibility that the agendas set will not appropriately reflect the needs of emerging economies. If the G8 were expanded to include the five outreach countries of Brazil, China, India, Mexico, and South Africa, then international health solutions crafted at that level would better reflect these needs. This type of expansion, however, demands much further research, given the current set of critiques regarding the G8’s efficiency and legitimacy (see Cooper 2007). In essence, the world must do more to share best practices. Many countries are doing extraordinarily interesting things, such as Thailand. It is particularly important to understand that everyone is in this together. It is essential to accept that we are one people, or we will destroy ourselves. In other words, despite the evolving health goals in today’s drastically different international milieu from the one of Shi Huangdi and Elizabeth Blackwell, their simple observations from centuries ago remain pertinent today: we cannot reduce ourselves to the role of tinkers who merely patch and mend what is broken. Rather, we must take a collaborative role as the guardians of the life and health of our generation, so that stronger and more able generations may come after us.

Note 1 Glouberman and Zimmerman (2002) say that Brazil ‘managed to falsify the World Bank prediction that it did not have the resources to resist HIV infection and would have 1.2 million cases of HIV/AIDS by 2000’.

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References Cooper, Andrew F. (2007). ‘The Logic of the B(R)ICSAM Model for G8 Reform.’ CIGI Policy Brief No. 1. Centre for International Governance Innovation, Waterloo ON. <www.cigionline.org : Publications : Policy Briefs> (September 2008). Douglas, Tommy (1984). ‘The Future of Medicare.’ <www.healthcoalition.ca/tommy.html> (September 2008). Glouberman, Sholom and Brenda Zimmerman (2002). Complicated and Complex Systems: What Would Successful Reform of Medicare Look Like? Commission on the Future of Health Care in Canada, Discussion Paper No. 8. Ottawa. <www.hc-sc.gc.ca/english/pdf/ romanow/pdfs/8_Glouberman_E.pdf> (September 2008). Health Canada (2005). ‘Communiqué.’ Global Pandemic Influenza Readiness: An International Meeting of Ministers of Health. 24–25 October. Ottawa. <www.hc-sc.gc.ca/ahc-asc/media/ nr-cp/2005/2005_fin_e.html> (September 2008). Health Canada (2008). ‘SARS.’ <www.hc-sc.gc.ca/dc-ma/sars-sras/index-eng.php> (September 2008). Lalonde, Marc (1974). A New Perspective on the Health of Canadians: A Working Document. Minister of Supply and Services Canada, Ottawa. <www.hc-sc.gc.ca/hcs-sss/com/fed/ lalonde_e.html> (September 2008). National Advisory Committee on SARS and Public Health (2003). Learning from SARS: Renewal of Public Health in Canada. Chaired by David Naylor. Ottawa. <www.phac-aspc. gc.ca/publicat/sars-sras/naylor> (September 2008). Public Health Agency of Canada (2004). ‘Global Public Health Intelligence Network.’ Ottawa. <www.phac-aspc.gc.ca/media/nr-rp/2004/2004_gphin-rmispbk_e.html> (September 2008). World Health Organization (1986). Ottawa Charter for Health Promotion. (Geneva: World Health Organization). <www.who.int/healthpromotion/conferences/previous/ottawa/en> (September 2008). World Health Organization (2005). WHO Outbreak Communications Guidelines. Geneva. <www.who.int/infectious-disease-news/IDdocs/whocds200528/whocds200528en.pdf> (September 2008). World Health Organization (2006). ‘International Health Regulations.’ Geneva. <www.who. int/csr/ihr/en> (September 2008). Zacher, Mark W. (2007). ‘The Transformation in Global Health Collaboration since the 1990s.’ In A.F. Cooper, J.J. Kirton, and T. Schrecker, eds., Governing Global Health: Challenge, Response, Innovation, pp. 19–27. (Aldershot: Ashgate).

Chapter 4

The WHO and SARS: The Challenge of Innovative Responses to Global Health Security Adam Kamradt-Scott

The role, authority, and autonomy of international organisations (IOs) remain a fiercely debated issue in contemporary international relations. Criticised for their democratic deficit, their (apparent) incapacitating politicisation, inefficiency, professed failures or perceived inaction, IOs are regularly condemned by policy makers, governments, activists, and academics alike (Pollack 2003; Esty 2006; Ruggie 1985). Indeed, even when IOs are widely observed to have acted in accordance with their delegation contract, they can still attract criticism. Given this state of affairs, it is often difficult to assess whether such criticisms are justified and whether IOs are truly the selfaggrandising, self-seeking tyrants that some suggest (Barnett and Finnemore 1999). This chapter examines one IO—the World Health Organization (WHO)—and a number of the criticisms that have been made of its role, authority, and autonomy in responding to the first new pandemic of the 21st century, namely severe acute respiratory syndrome (SARS). The emergence of SARS as a global threat in 2003 has been documented in considerable detail elsewhere (see Brooks 2005; Abraham 2005; WHO 2006c, and Chapter 3 in this volume). In this chapter, only the basic facts need revisiting. The disease originally began circulating in southern China in late 2002. It was carried to Hong Kong by an unsuspecting doctor in early 2003, who transmitted the virus to a number of international travellers, each of whom spread the disease to others upon their arrival at various destinations around the world. Some five months later, the disease had spread to 32 countries, had infected 8422 individuals, and had caused the deaths of some 916 people (WHO 2003b).1 The pandemic additionally contributed to massive social and political upheaval (particularly in those countries worst affected) and caused substantial economic damage estimated to be between US$11 billion to US$100 billion.2 Nevertheless, through an unprecedented, combined effort by public health experts, scientists, governments, and the WHO, the first new pandemic of the 21st century was not only contained in a remarkably short period of time, but was eradicated as well.3 Given that this was one instance when an IO appears to have performed beyond expectations, it is somewhat perplexing that a number of academic commentators

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have since questioned whether the WHO bureaucracy acted appropriately. For example, it has been argued that it acted as ‘international health police’ (Schnur 2006), that it engaged in agency slack (Cortell and Peterson 2006), and that it exercised ‘independent power’ (Fidler 2004). This chapter evaluates the last set of claims, namely, that the WHO engaged in agency slack or independent power in containing SARS by taking unauthorised, unprecedented, and undesired actions. These claims, advanced by David Fidler and by Andrew Cortell and Susan Peterson, additionally suggest that the WHO exceeded its authority and mandate, effectively engaging in ultra vires activities that contravened the preferences of its member states. However, while the methods the WHO employed may be considered unconventional, when compared against the organisation’s mandate, its delegation contract with member states to eradicate disease, and customary practice, the bureaucracy’s actions were consistent with the organisation’s envisaged role, authority, and autonomy. Moreover, although the WHO acted unilaterally (or autonomously) in the context of SARS, the actions taken by the bureaucracy had been previously authorised by member states and were in fact congruent with the intentions of its collective membership at the time of the pandemic. In conducting this analysis, this chapter contributes to the wider debate about the role of IOs and, in particular, the role of the WHO in global health governance. It also assesses the organisation’s ability and scope to engage in innovative means to fulfil its mandate of advancing global public health and the international community’s willingness to accept such innovation.

Post-SARS Claims Summarised Within a year of the WHO’s declaration that SARS had successfully been contained worldwide, Fidler (2004; 1998; 1999; 2001) published SARS, Governance, and the Globalization of Disease, which drew together a number of themes from previous publications to suggest that a new era of ‘post-Westphalian’ health governance has arrived. Although he claims that this new epoch had been developing for some time, Fidler (2004, 42–60) states that the 2003 SARS pandemic marked ‘the point at which a new governance paradigm for global infectious disease threats truly came of age’. The WHO’s actions in responding to SARS represented a ‘governance tipping point’ that established a precedent for how future disease outbreaks would be managed (187–189). One of the intrinsic elements in this new style of communicable disease governance, however, was the WHO’s apparent usage of ‘independent power’ (142). Intriguingly, Fidler never explicitly outlines the exact meaning of the phrase ‘independent power’. However, it appears that the WHO’s alleged independence relates to its issuance of geographically specific travel advisories and global alerts. As Fidler (2004, 188–189) summarises, WHO’s exercise of independent power during the SARS outbreak in issuing global alerts and geographically specific travel advisories … represent unprecedented developments

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in the history of the world politics of public health and perhaps even in the history of international organizations.

Fidler (2004, 139–145) also suggests that these recommendations were unauthorised, issued without consultation, and economically damaging to certain member states. The claims of WHO independence thereby relates not only to the substance of the recommendations and the manner in which the organisation issued them, but also their effect. This argument is best summarised as follows: In issuing alerts and advisories, WHO exercised significant power in the absence of any agreed policy or legal framework and without deference to the sovereignty of affected states. These actions revealed WHO as an autonomous actor influencing events directly rather than just acting as a convenient device for coordinating the sovereign behaviour of its member states. Without any express policy or legal basis for its actions, WHO took steps with serious political and economic consequences for states affected by SARS (Fidler 2004, 142).

A similar argument has been offered by Cortell and Peterson (2006, 255–271), who cite the WHO’s actions in containing the SARS pandemic as one case of an IO successfully engaging in ‘agency slack’ and ultimately amending its operational procedures and mandate. Combining principal-agent theory and constructivist approaches, they argue that the WHO demonstrated this slack, which has been defined as when an agent takes ‘independent action undesired by the principal’ (Hawkins et al. 2006, 8), first when it used public health information from nongovernmental sources to criticise China publicly, and second when it issued the global alerts and travel advisories (Cortell and Peterson 2006, 269–270). Cortell and Peterson contend that these actions demonstrated that the WHO’s bureaucracy (the agent) formed independent preferences distinct from its member states (the principals). Using the full range of institutional manoeuvring available to them, WHO staff then asserted their own preferences despite member states’ intentions to the contrary. Cortell and Peterson (269, 279–280) conclude, as a result, that the WHO used the 2003 SARS pandemic as an opportunity to engage in agency slack. While themes related to Fidler’s thesis do emerge (the most striking being the considerable similarity between independent power and agency slack), Cortell and Peterson’s (257) critique seeks to ‘explain when IOs can engage in slack and speculate on when they actually do’.4 Prior to evaluating these claims, however, it is necessary first to outline why they are significant. By arguing that the WHO’s bureaucracy engaged in agency slack, Cortell and Peterson have suggested, perhaps unwittingly, that the autonomy exercised by the organisation was in some way inappropriate. According to the framework they employ, only two forms of slack are possible: shirking, defined as ‘when an agent minimizes the effort it exerts on its principal’s behalf’, or slippage, which has been defined as ‘when an agent shifts policy away from its principal’s preferred outcome and toward its own preferences’ (Hawkins et al. 2006, 8). Although Cortell and Peterson argue that it was this latter form of agency slack that was affected by

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the WHO in the context of SARS, both forms of slack attract negative connotations (8–9). Agency slack has even been cited as evidence of dysfunctional or pathological IO behaviour (Barnett and Finnemore 1999, 715–716). The claims Cortell and Peterson advance thus suggest that while the eradication of SARS may have been a beneficial, even desirable, outcome, the role, authority, and autonomy the WHO’s bureaucracy displayed was nevertheless unanticipated, and consequently improper. An even more serious implication arising from the arguments of Fidler, Cortell, and Peterson is their bearing on the legal status of the WHO’s actions. By asserting that certain elements of its response were not authorised, Fidler, Cortell, and Peterson have classified the WHO response as ultra vires under international law. Where it can be determined that an IO has acted ultra vires or outside its authority and competence, the legality of that action may also be challenged (Akande 2003, 285; see also White 1996, 119). Until now no member state has disputed the legal status of the WHO’s actions, but these claims nevertheless cast significant doubt over them. Even if such charges were never raised, the suggestion of impropriety can still have serious ramifications. For instance, were the claims about the WHO’s so-called independence proven (or even assumed) to be correct, certain select member states, traditionally suspicious of the role and authority of IOs, could conceivably react by seeking to constrain how the WHO operates even further. New checks and balances on its constitutional authority may be adopted. Its powers to respond to such events may be curbed. Conversely, in an attempt to prevent objections over the management of an issue or event arising later, the WHO may decide to curtail its own activities. It may, for example, decide to refrain from issuing travel advisories if member states would likely later challenge their legality (and, by default, the legitimacy of the organisation). Both sets of circumstances remain, for the moment, hypothetical suppositions. Yet were they to arise, they would undoubtedly have a damaging effect on the WHO’s activities if only because the organisation’s attention would be temporarily diverted from its primary focus of improving health for all. By challenging the veracity of these claims, this chapter is not suggesting that asking probing questions about the actions of IOs is wrong. Rather, the behaviour of IOs, like states, should be regularly scrutinised and questioned. The key issue for academics and policy makers, however, is how to identify IO mission creep when it actually occurs. How can an IO perform as intended (or perhaps more accurately, how should an IO be performing) be distinguished from an IO that is exerting its own preferences above those of its member states? Can it be considered agency slack when the preferences of member states and the IO appear to be aligned? And, even more significantly, given the negative connotations associated with the term, can agency slack also be viewed as a positive development, a change for good that should be encouraged?

The WHO’s Actions Assessed The following analysis shows that some of these issues are not as straightforward as they seem. Indeed, the case presented below offers one view of the WHO bureaucracy’s

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behaviour in the case of SARS. Importantly, however, it focuses only on those aspects of the WHO’s response to SARS that Fidler, Cortell, and Peterson have identified as unauthorised, unprecedented, and conflicting with the preferences of its member states. This includes the WHO’s issuance of global alerts, geographically specific travel advisories, and criticism of the Chinese government. As little or no mention has been made of the other features of the WHO’s response, it has been assumed that the remaining elements are accepted as falling within the organisation’s general competence and authority. Thus, the argument here concentrates on establishing that the WHO was authorised to issue the global alerts and travel advisories and to criticise of one of its member states. Several assumptions underpin this argument and the context in which the WHO acted. The first is that IOs are actors in their own right (Hawkins et al. 2006; see also Barnett and Finnemore 2004, 1–10, 20–44). The second assumption is that the 2003 SARS pandemic was an exceptional epidemiological event. More precisely, although the Chinese authorities’ decision to break with customary international law of reporting disease outbreaks was not in itself particularly abnormal, their decision to ignore their responsibility aided the new contagion’s emergence and rapid dissemination. When the nature of the contagion then combined with spreading events and international air travel, governments, public health officials, and the WHO alike were presented with multiple, simultaneous outbreaks of a previously unknown disease. The subsequent numbers of affected healthcare workers and facilities additionally converged with the pervasive uncertainty surrounding the rapid international spread of the SARSassociated coronavirus, and, in contrast to many other disease outbreaks, the new and unknown disease directly threatened the populations of developed countries. When viewed collectively, these factors culminated in a very atypical epidemiological event materialising—one that was arguably exceptional. Equally significant is the context in which the WHO took these controversial actions. At the time that the SARS-associated coronavirus began to spread internationally the WHO was in the midst of revising the International Health Regulations (IHR) (Fidler 2004, 142). As the only treaty designed to combat the international spread of infectious diseases, the IHR is an integral component of the WHO’s diseaseeradication delegation contract with its member states. In 1995, recognising that the IHR legislation was inadequate to the task, the WHO’s member states authorised its bureaucracy to undertake an extensive reform of the policies and methods it used to combat infectious diseases (WHO 1995b; WHO 1995a). To that end, at the 48th World Health Assembly (WHA) the member states passed two resolutions: WHA48.7 Revision and Updating of the International Health Regulations and WHA48.13 Diseases Prevention and Control: New, Emerging, and Re-emerging Infectious Diseases. These required the director general to instigate a comprehensive programme to evaluate and update the legislative framework and to develop new ‘strategies enabling rapid national and international action to investigate and to combat infectious disease outbreaks and epidemics’ (WHO 1995a). It was intended that any changes to the WHO’s modus operandi would then be reflected in new draft legislation, which, once ratified by member states, would create a revised

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disease eradication framework (WHO 1995b). The key factor was that the WHO had been granted considerable discretionary capacity to experiment with developing new policies and disease-eradication procedures at the time SARS was spreading internationally. This is an important caveat that Fidler, Cortell, and Peterson appear to overlook in their criticisms of the WHO’s actions, but one that is integral to determining whether the organisation can be deemed to have engaged in independent actions undesired by its member states. Unauthorised, Unprecedented Actions The constitution of the WHO is the single most important document for determining the scope of the organisation’s authority and power. Throughout the 82 articles comprising the WHO’s constitutive treaty are a number of explicit rights, responsibilities, duties, and functions that the organisation has been authorised by its member states to perform. These capacities are commonly referred to as express powers, which are those powers ‘expressly granted by the constitution’ (Amerasinghe 2004, 100). Where expressly granted, these powers are classified as intra vires, or within the scope and authority of the organisation concerned. Some of the more prominent examples of the WHO’s express (intra vires) powers include the WHA’s authority to adopt regulations pertaining to sanitary and quarantine measures (WHO 2006a, art. 21[a]), the director general’s power to establish relations with other IOs undertaking health-related activities congruent with the WHO’s (art. 33), and the executive board’s authority to implement emergency measures when responding to events such as epidemics (art. 28[i]). Like the constitutive treaties of many IOs, however, the WHO’s constitution also has a number of limitations. Specifically, by virtue of its nature, it sets out the object and purpose of the organisation in very broad terms. Ascertaining the definitive boundaries of the WHO’s authority and the extent of the powers the organisation is entitled to affect on a daily basis can therefore be a complex and, at times, problematic exercise (Sands and Klein 2001, 445). One of the more serious implications of this limitation is that the actions or decisions of an IO may occasionally be viewed as unconstitutional and classified as ultra vires. The inevitable question that subsequently arises then is who is authorised to interpret an IO’s constitutive treaty. It is now widely accepted in the international legal tradition that where no one body has been explicitly named within an IO’s constitutive treaty to interpret the document, the organs of that particular organisation will provide the interpretation in the first instance.5 Like any treaty concluded between governments, however, the constitutive treaties of IOs are subject to a number of general rules of treaty interpretation, including that the treaty is to be interpreted in good faith, that ordinary meaning is to be ascribed to the text of the treaty, that the treaty should be interpreted in its context and in the light of its object and purpose, that subsequent practice is to be accepted as a form of interpretation and any subsequent agreements are to be taken into consideration, and that the meaning of the treaty should not be left ambiguous or unclear in any way (Evans 2005, 130–136).

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In addition, however, IO constitutive treaties have been recognised as possessing special character deserving of uncommon interpretive techniques. This principle, established by the International Court of Justice (ICJ) in its advisory opinion on the Legality of the Use by a State of Nuclear Weapons in Armed Conflict, stipulates that while the ‘well-established rules of treaty interpretation apply’, IO constitutive treaties, are also treaties of a particular type; their object is to create new subjects of law endowed with a certain autonomy, to which the parties entrust the task of realizing common goals. Such treaties can raise specific problems of interpretation owing, inter alia, to their character which is conventional and at the same time institutional; the very nature of the organization created, the objectives which have been assigned to it by its founders, the imperatives associated with the effective performance of its functions, as well as its own practice, are all elements which may deserve special attention when the time comes to interpret these constituent treaties (ICJ 1996, 4).

By virtue of this dual nature and the difficulties it raises, adjudicative bodies such as the ICJ have tended to adopt a more flexible approach when interpreting IO constitutive treaties. Special prominence has been attached to two features: the object and purpose of the treaty, and the role of subsequent practice. In the context of the WHO, the object and purpose of the treaty were to create a universal organisation charged with ensuring the ‘attainment by all peoples of the highest possible level of health’ (WHO 2006a, art. 1). Health, which was described by the WHO’s founders as ‘a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity’ (preamble), presupposes the absence of disease. The eradication of any disease such as SARS is thus a core component in achieving this objective—one entirely consistent with the object and purpose of the IO’s constitutive treaty. Correspondingly, it is likely that should a case about the WHO’s handling of SARS ever be brought before the ICJ, considerable latitude would be accorded to the WHO’s bureaucracy for its actions. In fact, several provisions within article 2 of the WHO constitution are particularly relevant to evaluating the WHO’s actions. The first two provisions of immediate significance—‘to act as the directing and co-ordinating authority on international health work’ (WHO 2006a, art. 2[a]) and ‘to stimulate and advance work to eradicate epidemic, endemic and other diseases’ (art. 2[g])—establish the organisation’s overall authority to respond and, importantly, to take the lead role throughout the 2003 SARS-inspired global emergency. Particularly in terms of the WHO’s authority to issue the global alerts, geographically specific travel advisories, and disease outbreak information to non-state entities, however, the follow provisions may be interpreted as further authorising the aforementioned activities: k) to propose conventions, agreements and regulations, and make recommendations with respect to international health matters and to perform such duties as may be assigned thereby to the Organization and are consistent with its objective (WHO 2006a, art. 2);

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Furthermore, under article 2(v) of the constitution, the WHO has been additionally empowered to ‘generally take all necessary action to attain the objective of the Organization’, which, as indicated previously, is the attainment of all peoples of the highest possible level of health. In reviewing these various provisions, it becomes difficult to agree with the view that the WHO’s recommendations throughout SARS were unauthorised. The WHO’s global alerts and travel advisories are classified as non-binding recommendations that the organisation is authorised to issue under article 2(k) of the constitution. Similarly, the WHO’s dissemination of disease outbreak notifications and updates via its website and the international media could clearly be interpreted as permissible activities under article 2(q) and (r). Lastly, eradicating the SARS-associated coronavirus was entirely consistent with both the overall objective of the WHO—the attainment of all peoples of the highest possible level of health—and its duty to eradicate disease. Thus, even from a brief overview of the WHO’s constitutional powers, it is reasonable to surmise that the bureaucracy’s actions were authorised. Likewise, a case can be made that established or customary WHO practice substantiates the validity of the organisation’s authority to issue the global alerts and travel advisories. First, the WHO has regularly issued global alerts pertaining to disease outbreaks whenever it has deemed them necessary. Prior to the mid 1990s these alerts were only generally published in the WHO’s weekly periodical, Weekly Epidemiological Record. However, since 1996, they have also been published on the WHO website (WHO 2008; 2006b). More specifically in relation to the geographically specific travel advisories, the WHO secretariat maintains that it has taken comparable action on at least one prior occasion, following the 1994 outbreak of plague in Surat, India. In this instance the WHO issued a recommendation that avoiding travel to the affected region was unnecessary (WHO 1994a; 1994b). Although the content of the recommendation was therefore technically the reverse of the SARS advisories (and as such, the case for customary practice is certainly debatable), the WHO secretariat maintains that this advisory established a precedent for the 2003 travel advisories.6 Strengthening the bureaucracy’s case, it is not only the practice of the organisation itself but also the reaction of member states that can provide new insight into the powers and authority of an IO. As Jose Alvarez (2005, 80) observes, action taken by a member with respect to an organization, if unchallenged by the organization or other members, may also constitute, de facto, an interpretation with such effects. The same is true of action taken for the first time by an institutional organ, if unchallenged by the membership. Even an interpretation by the legal department of the secretariat, if accepted by the membership, is presumed to be intra vires and may be cited as authoritative the next time a similar issue arises.

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It follows, then, that because member states failed to raise any specific objections to the Surat advisory at the time in 1994, they tacitly signalled their endorsement of this type of measure, laying the foundation for the 2003 SARS advisories. Indeed, the WHO legal department appears to have adhered to this line of reasoning. In extending this principle even further, the fact that no member state sought to challenge the legal status of the WHO’s actions throughout the 2003 pandemic negates the possibility that the organisation’s actions could be classified as ultra vires. Instead, by not challenging the WHO’s actions, member states concurred with the interpretation provided by the WHO bureaucracy that its actions in the context of SARS were authorised and within acceptable limits of IO behaviour (Osieke 1983).7 This is not to suggest, however, that no aspect of the WHO response to the 2003 SARS pandemic was unprecedented. Nor were the nature of the recommendations and the attention they subsequently generated lost on the WHO bureaucracy. As one senior WHO official overseeing the revision of the IHR observed, what I think was relatively new for WHO, at least in the immediate consciousness of the world, was that people looked very much to the organisation and what it said. And not just health experts or various ministries of health, but other people looked at it and took it very seriously. That is unusual. There’s nothing in our mandate that says it shouldn’t be done or that is an inappropriate thing for us to do. But I think the balance then between the organisation saying something and that then being interpreted, moderated, and adapted by member states, and then given to the public, was a little lost with many of the things WHO was saying being of direct interest and directly influencing not just members of the public, but other institutions, other organisations … that caused some change, a shift in how people perceived the organisation.8

In fact, it could be conversely argued that the WHO’s bureaucracy was not only entitled to take the actions it did, but also that it was actually obliged to do so, whether those actions were unprecedented or not. This was possibly no more readily apparent than in relation to the controversial travel advisories, as pointed out by David Heymann, who was the executive director of the WHO Communicable Diseases Cluster at the time of the pandemic: Before we started making our recommendations there were many countries that had made advisories that weren’t based on anything more than insurance concerns. One government, for example, recommended no travel to Vietnam. They also recommended that government employees’ families living in that country be returned home. These recommendations were made because the government could not ensure return flights should their citizens abroad become ill.9

The case could be made that the WHO, as the world’s independent authority on health matters, had a duty to provide an impartial assessment of the danger to and from the international public. The WHO’s bureaucracy was thus obliged to take the action it did, the authority to do so flowing naturally from its constitutional powers

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and established practice and, additionally, from its duty of care as an impartial, technical organisation charged with ensuring the eradication of disease. Indeed, if any aspect of the WHO’s management of the 2003 SARS pandemic was classified as an example of independent power or agency slack, it would be the bureaucracy’s earlier decision to send a team of scientists to China without a prior invitation from the Chinese government. This action, which precipitated the bureaucracy’s criticism of the Chinese authorities, clearly violated article 2(d) of the WHO constitution. By sending the team without any specific request or invitation, the bureaucracy appeared to contravene both its constitutional authority and the sovereignty of one of its member states. Again, however, it is important to note the context in which the WHO bureaucracy took this action prior to classifying it as an example of independent action undesired by its principal. As highlighted above, the WHO (1995a, para. 3(1–6)) had previously been commissioned to explore new disease-eradication policies and procedures. This request, issued by member states in 1995 in association with an express request to revise the IHR, granted the WHO bureaucracy additional discretionary capacity to explore new policies and operational procedures that would enhance its ability to fulfil its delegation contract to eradicate communicable disease threats. Moreover, at the time the 2003 SARS pandemic commenced, the IHR revision process was ongoing. As such, it can be assumed that the WHO’s bureaucracy was authorised to exercise discretion in how it responded to the SARS threat given that no formal legal framework had been established and given the fact that the additional capacity to explore alternative disease-eradication policies and procedures had not been rescinded. Furthermore, and especially significantly, member states had already tacitly sanctioned the WHO’s interventionist approach to communicable disease threats when they passed resolution WHA54.14 Global Health Security: Epidemic Alert and Response in 2001. In passing this resolution, member states expressed their unambiguous support for the multiple programmes and initiatives that the WHO’s bureaucracy had begun testing under the authority to revise the IHR (see WHO 2001a, esp. para. 1.3, 3.1–3.3). By default, they also sanctioned several new diseaseeradication operational policies and procedures, including the Global Outbreak Alert and Response Network (GOARN), which had been established in April 2000 (WHO 2000). According to this framework, the WHO is required to send a rapid response team whenever a disease outbreak is reported to conduct a risk assessment, offer technical advice and support, initiate field investigations, assemble epidemiological data and conduct research, and communicate any findings with the wider international community (WHO 2001b). Thus, the bureaucracy’s actions were entirely reasonable and consistent with the authority it had been previously granted by member states. Undesired Actions As noted above, it has been suggested that in issuing the global alerts and travel advisories and publicly criticising the Chinese government, the bureaucracy took actions that were undesired by member states (Fidler 2004, 141; Cortell and Peterson

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2006, 269–270, 279). However, on examination, the case supporting this observation falls down. The WHO is composed of 193 member states, all of which can possess divergent preferences and views. Given this reality, it is entirely reasonable to expect that member states will, from time to time, disagree with each other over the organisation’s planned course of action or activities. It is also entirely possible that while one or even a few member states will object to the direction or actions, not all member states will. This places the WHO’s bureaucracy in a precarious situation whereby the actions it takes may be congruent with the (often silent) majority of member states but vehemently objected to by a small minority. In the context of SARS, it is evident that the majority of member states fully supported the WHO’s decision to issue the alerts and travel advisories, and later to criticise the Chinese government, by the fact they declined to renounce the WHO’s behaviour. Only China formally objected to the WHO’s actions (the only protest from Canada was at a provincial level—the federal government did not object)— and even then the Chinese government declined to push the matter due to mounting pressure from the international community to cooperate with the WHO. In fact, evidence of the international community’s support for the WHO’s actions was made very apparent at the 56th WHA, convened in May 2003 at height of the pandemic. Throughout the assembly as well as the subsequent plenary meetings that followed in June, representatives from Sweden, the United Kingdom, Japan, the Maldives, South Korea, Brunei Darussalem, Turkey, Mongolia, Finland, the Czech Republic, Hungary, Singapore, Thailand, Pakistan, Jamaica, Zambia, Zimbabwe, the European Commission, and Vietnam announced their governments’ appreciation and continued support for the WHO’s management of the 2003 SARS pandemic (WHO 2003c, 160, 184; 2003d, 20–34; 2003e, 3–46). Aside from a comment made by the Chinese government representative, no mention was made that the WHO had overstepped its mandate or that it had taken actions that were either unauthorised or unprecedented. Even in private conversations there appears to have been no protest raised. As Heymann recalls, I’ve had the honour of speaking with the heads of many affected countries, and in those encounters there was never any telling WHO that we’d overstepped our mandate. What was said was ‘we understand the criteria, we understand why we’ve been put on this list. We want to get off as soon as we can’.10

Moreover, many member states pressed the WHO to take affirmative action. As one senior WHO legal official noted, it wasn’t done without demand for that to be done coming from member states. In other words, although there was no process, member states were asking us to take action in that timeframe, of that type. But there was not a consensus amongst the member states per se. There were individual demands from many member states. That we responded to such demands is entirely within what we are supposed to be doing according to our constitution.11

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Thus, given that demands were being made by individual member states without strident opposition from the vast majority of other state parties, it is reasonable to conclude that the majority of member states in fact supported the WHO’s methods, with their silence equating to tacit approval. It can similarly be concluded that the WHO’s actions in the context of the SARS pandemic were consistent as opposed to conflicting with the intentions of its collective membership. This argument is perhaps best summarised by the same senior WHO legal official, who stated: I don’t think WHO exercises independent power. What WHO does is respond to the direction of its member states, but at any one time not all member states will agree about what WHO’s actions should have been or should be. And WHO sometimes has to act, particularly in emergencies, on the basis of its mandate without consulting or getting agreement from all member states. Having said that, the basis that it acts then is on the basis of the expertise and the authority it has as an expert body in public health. Even having said that, it would still always seek to have, to inform, and to take into account the views of as many member states as it can, particularly those that are directly involved in the emergency. And so I wouldn’t call it independence; I’d call it some kind of moderated independence where we will act sometimes, and while not everyone of our member states will always agree with our actions, we would not act without agreement of at least many of our member states, and without consulting member states.12

Independent Action? This is not to suggest, however, that the WHO’s response to the 2003 SARS pandemic was orthodox. In what may be a highly unusual, even exceptional move, the WHO bureaucracy did act independently, rapidly, and forcefully to the SARS threat—a point that acknowledged by several senior WHO officials on more than one occasion, as well as in several official publications (WHO 2003f, 5–7) and by Gro Harlem Brundtland, former director general of the WHO.13 The observation that the organisation did not seek any specific permission from member states prior to responding to the SARS threat is not, therefore, in question. The WHO’s senior leadership took full advantage of the discretionary capacity granted to it, reallocating the organisation’s temporal, financial, material, and normative resources to combat the SARS virus. This point, however, does not equate to arguing the WHO’s leadership took these actions without regard to their impact upon member states. Nor is it being suggested that the WHO failed to advise member states of the action its bureaucracy was taking. Rather, it has been reported that the key decision makers were very well aware of the potential impact of their actions on member states, and these were discussed with the governments of those countries directly affected by SARS prior to the action being taken. As Heymann has noted, the director general in her deliberations and in her thinking asked ‘does this fit in with what the mandate of the Organization?’. We were very careful in how we approached this—we

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discussed with countries in advance of making the recommendations so that they knew that they were coming, and took into consideration any comments that they might have. It didn’t change our decision, but it did bring into consideration any comments that they had before we actually made the recommendations public.14

Similarly, in commenting on whether the issuance of travel advisories constitutes independent power, Bill Kean, WHO Director of Governance in 2003, stated that certainly Dr. Brundtland thought about that very carefully as to whether it was the right thing to do public health–wise. But as for the economic impact, was she able to act alone? [Brundtland] decided that she was. So independent? Well, it was independent of other bodies. I mean [Brundtland] didn’t consult the WTO [World Trade Organization] on the trading considerations or WTO tourism [World Tourism Organization] on the tourism implications … but the member states were advised that this action was happening.15

Although it is thus openly acknowledged the WHO’s bureaucracy did act unilaterally, the decision was approached cautiously and with regard to the impact upon member states. Indeed, the organisation’s ability to act autonomously was ultimately one of the key strengths of its response to the 2003 SARS pandemic. Had the bureaucracy failed to respond rapidly and forcefully, it is highly likely that SARS would have become yet another endemic disease, periodically reappearing to cause further human suffering and death. It was the WHO’s ability to act independently, without the requirement to convene committees and sit through extensive debates about the potential consequences of each decision, that enabled SARS to be contained and eradicated within four months of its spreading internationally. While it is agreed that there are inherent dangers associated with allowing IOs too much freedom, the 2003 SARS pandemic powerfully demonstrated that the autonomy of IOs can have positive outcomes.

Conclusion The very features that some have suggested were unauthorised, unprecedented, and undesired were, in the end, critical to the WHO’s success in containing and eradicating SARS. In issuing the global alerts and travel advisories, and in criticising the Chinese government for its lack of action, the WHO put the world on alert and embarrassed a recalcitrant member state into amending its behaviour. By acting autonomously, it was able to institute a variety of constitutionally authorised measures that proved effective in both rapidly containing the SARS-associated coronavirus and preventing its further dissemination. These methods were somewhat unconventional, particularly for the WHO—which has historically sought to avoid controversy. However, member states had explicitly requested that the organisation undertake a comprehensive programme of reforming its disease-eradication policies

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and procedures in the process of revising the IHR—a process that was incomplete at the time of SARS. Given that, compared to past pandemics, the 2003 SARS pandemic was an exceptional epidemiological event, the WHO was required to respond in an exceptional, innovative way. Furthermore, while the WHO did act unilaterally it did so with an awareness of the potential impacts of its actions on its members, and it followed a clearly defined, constitutionally valid course of action that was based on sound public health principles. A number of the bureaucracy’s actions, such as sending an uninvited team of experts to China without the government’s explicit request, were based on customary practice, having been previously endorsed by the WHA with the creation of the GOARN in 2000. Furthermore, at least at the time of the 2003 crisis, the WHO’s actions were entirely consistent with the preferences of its collective membership, given that when the WHO did take these unconventional measures, the majority of member states failed to denounce them. It is always valuable in the wake of tragic international events to reflect on the roles of actors and whether things could, or should, have been done differently. The questions that Fidler, Cortell, and Peterson raise about the WHO’s behaviour are therefore important if for no other reason than they make one pause to consider how much authority and autonomy the international community is willing to cede to IOs. When the WHO was created in 1946 its founders anticipated the organisation would evolve, developing new and innovative means to fulfil its mandate. In the context of SARS the WHO exceeded expectations, demonstrating that many of the former restrictions on the notification of disease outbreaks and how the organisation responded to these events more generally required a substantial re-think. Of course, one should not assume that the WHO is merely a benevolent public servant. The actions and behaviour of IOs require constant monitoring to avoid unwanted mission creep. At the same time, they are required to walk a very delicate line where, on one side, they must fulfil their mandates in a constantly changing world while, on the other, they must meet the (at times very diverse) expectations of member states. It is an unenviable, and quite often tenuous, position—one that the world continues to place them in. Perhaps analysts should be a little more lenient, therefore, and embrace the innovative attempts of IOs to respond to new global challenges, particularly when most individual states would concede that these challenges are well and truly beyond them to manage.

Notes 1 Note that this figure includes deaths due to nosocomial causes that were not part of the original pandemic but occurred afterward. 2 Estimates on the final costs attributed to the 2003 pandemic vary considerably; see, for example, U.S. General Accounting Office (2004, 4, 32), Asian Development Bank (2003, 75–77), and Brower (2003, 651), as well as page 30. 3 The WHO (2003a) declared the SARS pandemic contained on 5 July 2003.

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4 With the exception of Cortell and Peterson’s claim that a second episode of agency slack occurred when the WHO criticised China, the terms ‘agency slack’ and ‘independent power’ are otherwise so alike in content and analysis that for the purposes of this chapter they have been taken to be synonymous. 5 This general principle of international institutional law originally arose from the 1945 San Francisco conference establishing the United Nations. However, it has also since been endorsed by the International Court of Justice (ICJ) in the Certain Expenses of the United Nations case, which concluded that ‘each organ [of the UN] must, in the first place at least, determine its own jurisdiction’ (Jennings 1962, 1177). Although in one sense this principle elevates the organs of an IO above that of its member states, it nevertheless has become widely accepted due to the fact that the IO organs are charged with executing the organisation’s delegated duties, and therefore, the organs are deemed to be the most competent authority to interpret the charter (see Alvarez 2005, 80). 6 Interview with David Heymann, 15 November 2005, WHO, Geneva. This view was also supported Senior WHO Official A, 18 November 2005, WHO legal department, Geneva. 7 This default position is made even stronger whenever an IO explicitly asserts that its actions were taken in the fulfilment of its mandate (Akande 2003, 285–296; Shaw 2003, 1196; Schermers and Blokker 2003, 154, 163). 8 Interview with WHO Official B, 18 November 2005, WHO, Geneva. 9 Interview with Heymann. 10 Interview with Heymann. 11 Interview with Senior WHO Official A. 12 Interview with Senior WHO Official A. 13 Email correspondence with Gro Harlem Brundtland, 13 April 2006. 14 Interview with Heymann. 15 Interview with Bill Kean, WHO Director of Governance, 15 November 2005, WHO, Geneva.

References Abraham, Thomas (2005). Twenty-First Century Plague: The Story of SARS. (Baltimore: Johns Hopkins University Press). Akande, Dapo (2003). ‘International Organizations.’ In M.D. Evans, ed., International Law. (Oxford: Oxford University Press). Alvarez, Jose (2005). International Organizations as Law-Makers. (Oxford: Oxford University Press). Amerasinghe, Chittharanjan F. (2004). Principles of the Institutional Law of International Organizations. 2nd ed. (Cambridge: Cambridge University Press). Asian Development Bank (2003). Outlook 2003 Update: Trends, Analysis, Projections. (Manila: Asian Development Bank). Barnett, Michael and Martha Finnemore (1999). ‘The Politics, Power, and Pathologies of International Organizations.’ International Organization, vol. 53, no. 4, pp. 699–732. Barnett, Michael and Martha Finnemore (2004). Rules for the World: International Organizations in Global Politics. (Ithaca: Cornell University Press). Brooks, Tim (2005). Behind the Mask: How the World Survived SARS. (Washington DC: American Public Health Association).

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Brower, Vicki (2003). ‘Health Is a Global Issue.’ EMBO Reports, vol. 4, no. 7, pp. 649–651. <www.nature.com/embor/journal/v4/n7/full/embor892.html> (September 2008). Cortell, Andrew and Susan Peterson (2006). ‘Dutiful Agents, Rogue Agents, or Both? Staffing, Voting Rules, and Slack in the WHO and WTO.’ In D.G. Hawkins, D.A. Lake, D.L. Nielson, et al., eds., Delegation and Agency in International Organizations, pp. 255–280. (Cambridge: Cambridge University Press). Esty, Daniel C. (2006). ‘From Local to Global: The Changing Face of Environmental Challenge.’ SAIS Review, vol. 26, no. 2, pp. 191–197. Evans, Malcolm D., ed. (2005). Blackstone’s Statutes: International Law Documents. 7th ed. (Oxford: Oxford University Press). Fidler, David P. (1998). ‘Microbrialpolitik: Infectious Disease and International Relations.’ American University International Law Review, vol. 14, no. 1, pp. 1–53. Fidler, David P. (1999). International Law and Infectious Diseases. (Oxford: Oxford University Press). Fidler, David P. (2001). ‘Return of “Microbialpolitik”.’ Foreign Policy, no. 122, pp. 80–81. Fidler, David P. (2004). SARS: Governance and the Globalization of Disease. (New York: Palgrave Macmillan). Hawkins, Darren G., David A. Lake, Daniel L. Nielson, et al. (2006). ‘Delegation under Anarchy: States, International Organizations, and Principal-Agent Theory.’ In D.G. Hawkins, D.A. Lake, D.L. Nielson, et al., eds., Delegation and Agency in International Organizations, pp. 3–38. (Cambridge: Cambridge University Press). International Court of Justice (1996). Legality of the Use by a State of Nuclear Weapons in Armed Conflict (Request for Advisory Opinion by the World Health Organization). 8 July. Geneva. <www.icj-cij.org/docket/files/93/10405.pdf> (September 2008). Jennings, R.Y. (1962). ‘International Court of Justice. Advisory Opinion of July 20, 1962.’ International and Comparative Law Quarterly, vol. 114, no. 1169–1183. Osieke, Ebere (1983). ‘The Legal Validity of Ultra Vires Decisions of International Organizations.’ American Journal of International Law, vol. 77, no. 2, p. 248. Pollack, Mark (2003). The Engines of European Integration: Delegation, Agency, and Agenda Setting in the European Union. (Oxford: Oxford University Press). Ruggie, John G. (1985). ‘The United States and the United Nations: Towards a New Realism.’ International Organization, vol. 39, no. 2, pp. 343–356. Sands, Philippe and Pierre Klein (2001). Bowett’s Law of International Institutions. 5th ed. (London: Sweet and Maxwell). Schermers, Henry G. and Niels M. Blokker (2003). International Institutional Law. 4th rev. ed. (Boston: Martinus Nijhoff). Schnur, Alan (2006). ‘The Role of the World Health Organization in Combating SARS, Focusing on the Efforts in China.’ In A. Kleinman and J.L. Watson, eds., SARS in China: Prelude to a Pandemic. (Berkeley: Stanford University Press). Shaw, Malcolm N. (2003). International Law. 5th ed. (Cambridge: Cambridge University Press). United States General Accounting Office (2004). Emerging Infectious Diseases: Asian SARS Outbreak Challenged International and National Responses. United States General Accounting Office, Washington DC. <www.gao.gov/cgi-bin/getrpt?GAO-04-564> (September 2008). White, Nigel (1996). The Law of International Organisations. (Manchester: Manchester University Press).

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World Health Organization (1994a). ‘Plague, India.’ Weekly Epidemiological Record, vol. 69, no. 39, p. 290. World Health Organization (1994b). ‘Plague, India.’ Weekly Epidemiological Record, vol. 69, no. 40, p. 295. World Health Organization (1995a). ‘Communicable Diseases Prevention and Control: New, Emerging, and Re-emerging Infectious Diseases.’ WHA48.13. Geneva. <policy.who.int/cgibin/om_isapi.dll?infobase=wharec-e&softpage=Browse_Frame_Pg42> (January 2007). World Health Organization (1995b). ‘Revision and Updating of the International Health Regulations.’ WHA48.7. Geneva. <policy.who.int/cgi-bin/om_isapi.dll?infobase=wharece&softpage=Browse_Frame_Pg42> (January 2007). World Health Organization (2000). Global Outbreak Alert and Response: A Report of a WHO Meeting. WHO/CDS/CSR/2000/3. Geneva. <www.who.int/csr/resources/publications/ surveillance/WHO_CDS_CSR_2000_3/en> (September 2008). World Health Organization (2001a). ‘Global Health Security: Epidemic Alert and Response.’ WHA54.14, 21 May. Geneva. (May 2008). World Health Organization (2001b). A Framework for Global Outbreak Alert and Response. WHO/CDS/CSR/2000/2. Geneva. <www.who.int/csr/resources/publications/surveillance/ WHO_CDS_CSR_2000_2/en> (September 2008). World Health Organization (2003a). ‘Update 96—Taiwan, China: SARS Transmission Interrupted in Last Outbreak Area.’ 5 July. Geneva. <www.who.int/csr/don/2003_07_05/ en> (September 2008). World Health Organization (2003b). ‘Summary Table of SARS Cases by Country, 1 November 2002 – 7 August 2003.’ 15 August. Geneva. <www.who.int/csr/sars/country/2003_08_15/ en> (September 2008). World Health Organization (2003c). Fifty-Sixth World Health Assembly: Summary Records of Committees and Round Tables, Reports of Committees. (Geneva: World Health Organization). World Health Organization (2003d). Provisional Verbatim Record of the Second Plenary Meeting: Address by the Director-General. (Geneva: World Health Organization). World Health Organization (2003e). Provisional Verbatim Record of the Second Plenary Meeting: Address by the Director-General, Continued. (Geneva: World Health Organization). World Health Organization (2003f). Severe Acute Respiratory Syndrome (SARS): Status of the Outbreak and Lessons for the Immediate Future. 20 May. Geneva. <www.who.int/csr/ media/sars_wha.pdf> (September 2008). World Health Organization (2006a). ‘Constitution of the World Health Organization.’ 45th ed. Geneva. <www.who.int/entity/governance/eb/who_constitution_en.pdf> (September 2008). World Health Organization (2006b). ‘Disease Outbreak News.’ Geneva. <www.who.int/csr/ don/archive/year/1996/en> (September 2008). World Health Organization (2006c). SARS: How a Global Epidemic Was Stopped. (Geneva: World Health Organization). World Health Organization (2008). ‘WHO Epidemic and Pandemic Alert and Response.’ Geneva. <www.who.int/csr/don/en> (September 2008).

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Part III Preparing for Pandemics: Avian Influenza

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Chapter 5

SARS and Avian Influenza in China and Canada: The Politics of Controlling Infectious Disease Sonny Shiu-Hing Lo1

Since the outbreak of avian influenza in Hong Kong in December 1997, infectious disease has become a human and national security threat to the Asia Pacific region (Osterholm 2005). In Asian cities where population density is high, such as Hong Kong, Singapore, and Macao, the emergence of any influenza pandemic endangers the lives of all citizens. In geographically spacious countries, notably the People’s Republic of China (PRC) and Indonesia, any looming pandemic would be socially destabilising and politically delegitimising. In the United States the Spanish influenza that broke out in 1918 resulted in civil disorder and riots in some cities (Garrett 2005). Public health crises have been numerous in the Asia Pacific region: avian influenza in Hong Kong in late 1997; dengue fever in Macao in 2000; severe acute respiratory syndrome (SARS) in mainland China, Hong Kong, and the Republic of China (ROC) or Taiwan in early 2003; avian influenza in China in 2004 and intermittently in 2005 and 2006; avian influenza in Indonesia and Thailand in 2005 and 2006; the H5N1 virus in South Korea in November 2006; and a suspected mysterious influenza that killed four children in Hong Kong in early 2008. In early 2007, avian influenza erupted in Japan, Thailand, and Indonesia (‘Bird Flu Strikes Again in Thailand’ 2007). All these health crises in Asia stemmed from infectious diseases, the most important of which include avian influenza and SARS. Infectious diseases are viruses that can be transmitted either from animals to humans or from humans to humans. This chapter focusses on the respiratory type of infectious disease, notably avian influenza and SARS. In this era of globalisation, avian influenza and SARS can extend their tentacles swiftly, especially if they can be transmitted from animals to humans and then from humans to humans. The intensity of air travel in the world means that any contagious disease in Asia has immediate economic, social, and political repercussions in other parts of the world (Thomson and Hoe 2004). Due to Canada’s proximity to Asia and their frequent human interactions, any influenza pandemic in Asia will wreak havoc on the Canadian economy. The

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Innovation in Global Health Governance

SARS outbreak in greater China—the PRC, Taiwan, Hong Kong, and Macao— severely affected Toronto, although Vancouver was largely spared from the crisis. In the wake of SARS, avian influenza has become the foremost health threat confronting Asia and the world. As the World Health Organization ([WHO] 2004a) warns, ‘of the 15 avian influenza virus subtypes, H5N1 is of particular concern for several reasons. H5N1 mutates rapidly and has a documented propensity to acquire genes from viruses infecting other animal species … isolates from this virus have a high pathogenicity and can cause severe disease in humans’. The migratory routes of birds from Siberia cover Asia and Europe. In February 2007, the H5N1 virus killed 2500 turkeys on a British poultry farm. If the H5N1-infected birds pose an increasing human security threat to many states and cities, the continuous surveillance of their migratory patterns by satellites is critical to the well-being of all the people around the world. Margaret Chan stressed the need to set up a global surveillance system to monitor health crises during her campaign for election as director general of the WHO in November 2006. After all, the H5N1 virus entails the possibility of person-to-person transmission in Thailand in 2004 (Ungchusak et al. 2005). If so, it is urgent for states to ‘stockpile anti-viral drugs and strain-specific vaccines’ and to share their intelligence data on the H5N1 virus with the WHO and other countries (Monto 2005, 325). According to the Canadian Influenza Pandemic Plan, any outbreak of the influenza An epidemic will have an immediate impact on Canada’s society and economy. An estimated 4.5 million to 10.6 million Canadians would become clinically ill and lose their working capacity (Public Health Agency of Canada [PHAC] 2004, 18). An estimated 2.1 million to 5 million people would require outpatient care; between 34 000 and 138 000 people would require hospitalisation; and between 11 000 and 58 000 people would die in Canada alone. The economic impact has been estimated to cost between CA$10 billion and CA$24 billion. This chapter analyses the governance of Asian states in response to respiratory infectious disease, particularly avian influenza and SARS. Lessons can be drawn from the Asian experience for Canadian governments at the federal, provincial, and municipal levels. Indeed, Canada has much to learn from the bitter lessons of SARS and the ways in which some Asian cities such as Singapore and Ho