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
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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
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6
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The Role of Civil Society in Pandemic Preparedness Kathryn White and Maria Banda
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In-Flew-Enza: Pandemic Influenza and Its Security Implications Yanzhong Huang
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Part IV Accessing Affordable Medicines 8 Coming to Terms with Southern Africa’s HIV/AIDS Epidemic Hany Besada
155
vi
9
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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
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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
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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
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14 Explaining Compliance with G8 Health Commitments, 1996–2006 John J. Kirton, Nikolai Roudev, Laura Sunderland, and Catherine Kunz
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15 Global Health Initiatives: A Healthy Governance Response? Caroline Khoubesserian
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Part VII Conclusion 16 Innovation in Global Health Governance John J. Kirton and Andrew F. Cooper
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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
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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
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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
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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.
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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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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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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 Hong Kong dealt with it. Being a democratic country does not necessarily endow federal and sub-federal governments with the capacity to control an influenza pandemic effectively. Arguably, governmental decisiveness during any such pandemic would be far more important than the protection of civil liberties. Provincial variations in Canada have already revealed on how differently those governments perceive an influenza pandemic. Yet if Canadian governments at the federal, provincial, and municipal levels together with the private sector all implement a common action plan, Canada’s governance in response to any possible influenza pandemic would be substantially enhanced. For the purposes of this chapter, the concept of health governance is defined narrowly as how governments respond to the outbreak of infectious disease. It refers here to government’s capacity or ability to take decisive and emergency measures. How a government reacts can have a direct bearing on the regime’s legitimacy. The
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more effective the governmental response is, the stronger the regime’s legitimacy will be. However, the external ramifications of the domestic response to infectious disease are outside the scope of this chapter. Indeed, the weaker the governmental response to the outbreak of infectious disease, the stronger the likelihood of the spread of the disease to the outside world. This narrow definition of health governance contributes to a deeper understanding of the political impact of infectious disease on a particular regime, even if many scholars define health governance as embracing various external and internal actors, such as the WHO, civil society, and nongovernmental organisations (NGOs).
Governmental Capacity to Respond to Infectious Disease in Asia The improvement of health governance is the most important challenge in globalisation. Both human security and national security are at stake because of the speed at which infectious diseases can be transmitted to a large segment of the local population. SARS is a typical example. Since the origin of the disease was related to the consumption of civet cats among Chinese residents in Guangdong province, the PRC’s health governance can be measured in terms of its ability to prevent its citizens from eating wild animals from live-animal markets that have been thriving since the country’s economic boom (Paterson 2004; Bonn 2003). Other barometers that measure China’s health governance include the flow of communications between the central government and provincial as well as local governments during an outbreak of infectious disease, the ability of the central government to mobilise in order to contain the spread of the deadly virus, and the compliance of provincial and local authorities in tackling the health crisis. Three indicators are critical to enhancing governmental capacity: preparedness, openness, and responsiveness. In the case of SARS, governments in Asia and Canada were totally unprepared.2 Canada was as poorly prepared as Hong Kong. Table 5-1 shows that the case fatality ratio in Canada was 17 percent, the same as that of Hong Kong, where SARS left an indelible imprint and a painful memory. Other Asian states witnessing a relatively high ratio of case fatality were Singapore, Thailand, Taiwan, Malaysia, the Philippines, and Vietnam. The PRC had the largest number of people infected with SARS. Although its case fatality ratio was claimed to be 7 percent, 349 people died of the mysterious disease (WHO 2004b).Canada’s performance during the SARS outbreak might not be an accurate indicator of how it would react to another new epidemic. Some argue that SARS did not appear to necessitate any stringent or draconian measures from the Canadian government. This argument is flawed. True, the SARS crisis was unprecedented and microbiologists could not quickly predict whether it would be temporary or not. But given the case fatality ratio in Canada, Ottawa and the provincial governments underestimated the speed at which SARS could affect the Canadian population. Canada learned a bitter lesson from its SARS experience. The report published by the National Advisory Committee on SARS and Public Health (2003a) recommended a better mechanism
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for the federal and provincial governments to strengthen their disease surveillance programmes. It also recommended harmonising public health legislation at both levels of government (215). The report concludes: ‘The challenge now is to ensure not only that we are better prepared for the next epidemic, but that public health in Canada is broadly reviewed so as to protect and promote the health of all our present and future citizens’ (220). Other critics pointed to many cases of misdiagnosis of Table 5-1: SARS and the Impact on Various Countries and Places, 1 November 2002 to 31 July 2003
Cumulative number of cases
No. of Case fatality Onset first Onset last Areas Female Male Total deaths ratio (%) probable case probable case Australia 4 2 6 0 0 26 Feb 2003 1 Apr 2003 Canada 151 100 251 43 17 23 Feb 2003 12 Jun 2003 China 2674 2607 5327 349 7 16 Nov 2002 3 Jun 2003 Hong Kong 977 778 1755 299 17 15 Feb 2003 31 May 2003 Macao 0 1 1 0 0 5 May 2003 5 May 2003 Taiwan 218 128 346 37 11 25 Feb 2003 15 Jun 2003 France 1 6 7 1 14 21 Mar 2003 3 May 2003 Germany 4 5 9 0 0 9 Mar 2003 6 May 2003 India 0 3 3 0 0 25 Apr 2003 6 May 2003 Indonesia 0 2 2 0 0 6 Apr 2003 17 Apr 2003 Italy 1 3 4 0 0 12 Mar 2003 20 Apr 2003 Kuwait 1 0 1 0 0 9 Apr 2003 9 Apr 2003 Malaysia 1 4 5 2 40 14 Mar 2003 22 Apr 2003 Mongolia 8 1 9 0 0 31 Mar 2003 6 May 2003 New Zealand 1 0 1 0 0 20 Apr 2003 20 Apr 2003 Philippines 8 6 14 2 14 25 Feb 2003 5 May 2003 Ireland 0 1 1 0 0 27 Feb 2003 27 Feb 2003 Korea 0 3 3 0 0 25 Apr 2003 10 May 2003 Romania 0 1 1 0 0 19 Mar 2003 19 Mar 2003 Russia 0 1 1 0 0 5 May 2003 5 May 2003 Singapore 161 77 238 33 14 25 Feb 2003 5 May 2003 South Africa 0 1 1 1 100 3 Apr 2003 3 Apr 2003 Spain 0 1 1 0 0 26 Mar 2003 26 Mar 2003 Sweden 3 2 5 0 0 28 Mar 2003 23 Apr 2003 Switzerland 0 1 1 0 0 9 Mar 2003 9 Mar 2003 Thailand 5 4 9 2 22 11 Mar 2003 27 May 2003 United Kingdom 2 2 4 0 0 1 Mar 2003 1 Apr 2003 United States 13 14 27 0 0 24 Feb 2003 13 Jul 2003 Vietnam 39 24 63 5 8 23 Feb 2003 14 Apr 2003 Source: Based on WHO (2004b).
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SARS because of a guiding protocol saying that patients with a cough, fever, and shortness of breath exhibited symptoms of tuberculosis (TB) (Bugl 2007, 710). Clearly, Canada must learn from any inadequacies in its crisis management of SARS. The Asian experience revealed variations in the openness of different states and cities under the onslaught of infectious diseases. In late 1997, when the H5N1 virus loomed in Hong Kong, there was speculation that it might have originated in South China. At the beginning, the Hong Kong Special Administrative Region (HKSAR) government was tightlipped on the origin of the avian influenza for fear of antagonising Beijing. Encountering the mysterious death of a few citizens, a crossdepartmental coordination committee headed by Anson Chan, former chief secretary for administration, boldly decided to slaughter 1.2 million chickens and birds to prevent the spread of the virus. The Hong Kong government extracted samples of chickens imported from China to see whether they were infected with H5N1—a move that marked the abandonment of its politically correct stance. Hong Kong’s relative openness in dealing with the avian influenza was mainly attributable to its vibrant mass media and dense population. In heavily populated cities like Hong Kong and Singapore, governments cannot afford the luxury of being slow in dealing with infectious disease. Singapore responded to SARS quickly and effectively, forcing suspected SARS carriers and patients into compulsory confinement where surveillance cameras were put in place.3 The relative openness of the Hong Kong and Singapore governments in tackling SARS contrasts sharply with the PRC. At the early phase of the outbreak of the mysterious virus, Beijing encountered a cover-up by local governments in Guangdong province. In April 2003, when President Hu Jintao dismissed the minister of health and the mayor of Beijing for mishandling SARS, the central government began to mobilise the localities and mass media to address the crisis (Zhang and Fleming 2005). Due to the need to protect China’s image as a regional and global power, its leadership sensed the urgency of containing the infectious disease (Saich 2006). Any failure to do so would undermine the PRC’s global image as a responsible international actor controlling the transnational transmission of infectious disease. China’s belated openness was partly attributable to pressure from the WHO. Its representatives in Beijing pushed the central government to be more transparent about the occurrence of SARS cases. Still, when WHO delegates were sent to inspect Beijing’s 301 Military Hospital, the Hong Kong media revealed that SARS patients had already been transferred to other places outside the purview of WHO investigators. The WHO issued travel advisories that recommended that travellers consider postponing their trips to Hong Kong and the PRC between April and May 2003, an action that was arguably too mild and yet diplomatic. China’s response to SARS was comparable to other Asian states affected by avian influenza. In February 2004, Indonesia admitted that an outbreak of avian influenza had occurred August 2003 (Revill 2005, 183). Thai authorities were alleged to have covered up an outbreak of avian influenza for the sake of protecting the country’s exports of poultry (see Greger 2006). While Singapore responded
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to SARS decisively, China’s reaction and that of Indonesia and Thailand to avian influenza showed that Asian regimes differed in their infectious disease control. The governmental capacity of Singapore and Hong Kong was forced to be strong, due mostly to their congested nature. In geographically spacious states, such as China and Indonesia, the problem of localism represents a fundamental obstacle to any fight against infectious disease. Table 5-2 shows that the larger a country, the more relaxed its approach to public health crises. Endowed with a large territory, PRC leaders at the central and local levels were at first relaxed about the outbreak of SARS, until it affected other parts of the world and generated international concern. If a regime is more open toward infectious disease control, it tackles the crisis more effectively. Although Singapore is viewed by some scholars as being an authoritarian polity, it displayed a relatively high degree of openness in controlling SARS.4 Similarly, the media scrutiny of Hong Kong’s administration and its transparency in reporting the development of SARS illustrated the government’s openness. However, given the lack of decisiveness and poor coordination by Hong Kong leadership, it was less effective in infectious disease control than Singapore (see Table 5-3). Regime openness in tackling health crises and the size of a state or a city directly determine that effectiveness. Furthermore, leadership decisiveness and departmental coordination are both critical to the responsiveness to the outbreak of infectious diseases. Overall, the effectiveness in disease control is shaped by such factors as the size of a state Table 5-2: Infectious Disease Control, Regime Openness, and Size Regime openness in disease control Size of a state or city
Low degree
High degree
Small
Moderate degree of effectiveness High degree of effectiveness in in disease control infectious disease control (Singapore)
Large
Low degree of effectiveness (People’s Republic of China)
Moderate degree of effectiveness
Table 5-3: Infectious Disease Response, Leadership Decisiveness, and Departmental Coordination Leadership decisiveness in disease control Departmental Coordination
Low degree
High degree
Weak
Low degree of responsiveness to disease outbreak (Hong Kong)
Strong
Moderate degree of responsiveness High degree of responsiveness to to disease outbreak disease outbreak (Singapore)
Moderate degree of responsiveness to disease outbreak
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or city, regime transparency in tackling health crises, and regime responsiveness, which embraces leadership decisiveness and departmental coordination. Responsiveness is an indispensable indicator of governmental capacity. It involves the degree to which political leaders take action to cope with infectious disease, whether departmental agencies communicate and coordinate with each other without squabbling, whether sufficient surveillance and quarantine measures are taken, whether public and private sectors cooperate with each other and mobilise citizens against communicable disease, whether citizens are resilient in coping with the health crisis, whether international collaboration is forged, whether the epidemiological diagnosis of the virus is swift, and whether vaccines are utilised fairly and effectively. In brief, responsiveness embraces political leadership, interdepartmental communication and coordination, surveillance and quarantine measures, public-private partnerships, public resilience, international cooperation, and epidemiological treatment. In Hong Kong, political leadership was wanting in the initial phase of the avian influenza outbreak in December 1996 and early January 1997. As more people succumbed to the deadly virus, the intergovernmental coordination committee had no choice but to slaughter all the chickens—a turning point in the evolution of political leadership. Nevertheless, it took the HKSAR government eight years from the outbreak of avian influenza to decide in 2008 that all the chickens and ducks would have to be slaughtered in a centralised house in 2010. By contrast, in Singapore, since 1993 all poultry has been required to be processed at a slaughtering plant approved by the Agri-Food and Veterinary Authority (Legislative Council of the HKSAR 2006, 3). The different approaches adopted by Hong Kong and Singapore fully revealed the former’s indecisive indecisiveness and the latter’s political will. Communication and coordination proved to be the weak dimensions of disease control in Hong Kong, Taiwan, and Mainland China. At the beginning of the 1997 avian influenza outbreak, the former chief of Hong Kong’s Department of Health, Margaret Chan, announced that she ate chickens every day—a remark that provoked severe criticisms later as more people infected with the disease passed away.5 In 2003, communication between the HKSAR government and the public was initially plagued by a bureaucratic refusal to admit the severity of the problem. Yeoh Engkiong, the secretary of health, welfare, and food, maintained that the mysterious virus did not spread to the community. Yet the deadly disease penetrated the society rapidly and soon the critical situation discredited him. Although the HKSAR government later daily reported the number of citizens infected with SARS, the entire crisis demonstrated the problems in communication and coordination between the Hospital Authority and the public, and between the Hospital Authority and private hospitals. The privately owned Baptist Hospital failed to report the conditions of suspected SARS patients to the Hospital Authority and the government. Moreover, Chan reportedly had reservations about whether the suspected SARS-infected residents in Amoy Gardens, in Kowloon, should be segregated and quarantined.6 When the index patient carrying the SARS virus from China stayed in Ward 8A of the Prince of Wales Hospital, opinions between the hospital authorities from the
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Chinese University of Hong Kong and government officials differed. The former wanted to shut down the hospital, but the latter refused to do so. In early 2003, during the SARS crisis, communication between PRC health authorities and their Hong Kong counterparts was by no means institutionalised. China and Hong Kong have since improved their cross-border communication by reaching an agreement on information sharing, informing the other side of any health crisis and conducting collaborative research on infectious disease. The Macao government has also been incorporated into the regional communications network, facilitating health information exchange. In early 2008, the outbreak of influenza in Hong Kong, Macao, and South China prompted the three governments to hold health awareness and information meetings to hammer out solutions and enhance mutual cooperation. With regard to surveillance and quarantine measures, during the SARS outbreak the HKSAR government installed infrared temperature-testing equipment at the airport and ports so as to identify potential disease carriers. The equipment was a useful tool by which immigration and health officials tracked down SARS-infected victims. Singapore’s surveillance was the most impressive in Asia, mobilising nurses and doctors dressed in fully protective gowns and masks to treat SARS patients, who had to use cordless phones and video-conferencing to communicate with their close relatives.7 Public-private partnership could be seen in Hong Kong’s tackling of SARS. Government and civil society organisations mobilised to resist the mysterious disease. The media contributed tremendously to the processes of scrutinising governmental management of SARS, exposing the problem of inadequate facilities and criticising reckless remarks made by government officials and Hospital Authority leaders. In contrast, China’s media organs were relatively weak, failing to reveal the spread of the disease until the central government gave the green light to launch an antiSARS campaign. The pressure on the media in mainland China to censor themselves was particularly strong during the annual meeting of the National People’s Congress (NPC) in Beijing in March 2003. Without the determination of President Hu and Premier Wen Jiabao to tackle the problem of SARS, it is doubtful whether the local media in the SARS-infected provinces could have triggered the alarm first and openly reported the health crisis. Public resilience was prominent in both Hong Kong and China, where numerous healthcare workers tragically succumbed to the disease. Despite the rising number of deaths in both places, health workers displayed their professionalism and loyalty by resisting the SARS epidemic to the end. Yet, psychologically, many ordinary citizens of Hong Kong suffered tremendously from the continuous reports of deaths in the early half of 2003. Healthcare workers in Taiwan experienced a certain degree of demoralisation. A few were so frightened of the disease that they escaped from their hospital by jumping out of its windows. Hospital chiefs squabbled over the SARS solutions—a phenomenon complicated by the politicised nature of hospital administrators loyal to political parties of differing ideologies. Exacerbating Taiwan’s weak capability was its inability to partake in the WHO as a member. Taiwan’s limited governmental
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capacity arose because it lacked experience, unlike the HKSAR, which had earlier endured the assault from avian influenza. In May 2006, Taiwan’s tenth attempt to achieve observer status at the WHO failed. The Taiwan government complained that it was due to the PRC opposition.8 In June 2006 the WHO website listed Taiwan as one of the areas apart from the PRC infected with avian influenza. Taiwan’s foreign ministry protested because the information provided on the website was misleading and hurt the island republic’s image in tourism, international trade, and human security.9 Both the United States and Canada supported Taiwan’s participation in the WHO as an observer, but the PRC insisted that Taiwan is part of China and therefore was ‘ineligible’.10 Although as director general of the WHO Margaret Chan vowed to assist Taiwan in its participation in WHO technical activities, it remains to be seen how it can be effectively brought under the WHO umbrella for combating infectious disease.11 In the wake of the victory of the pro-reunification candidate Ma Ying-jeou in Taiwan’s presidential election in 2008, prospects for rapprochement between Taipei and Beijing appear to be cautiously optimistic. Ma’s KMT has advocated that Taiwan should enter the WHO under the name of Zhonghua Taiwan [Chinese, Taiwan]. Obviously, the KMT has tried to test the diplomatic position of the PRC side. Regardless of the political tug of war between Taiwan and mainland China, Taiwan’s entry into the WHO would undoubtedly help the island prevent itself from being plagued by another outbreak of a SARS-type disease. Both Hong Kong and China cooperated with the WHO during the SARS crisis in 2003. The outbreak of avian influenza in China in 2005 and 2006 raised the question of sharing samples for virus testing with the WHO, but WHO representatives in China complained that Beijing was reluctant to provide samples for further experiments. Chan, however, vowed to remain impartial toward the PRC, which had lobbied many countries to vote for her. Indeed, with the election of Canadian-trained Chan as its head, the WHO is encountering the challenge of engaging China to bring it into the orbit of improved cooperation.12 In the SARS and avian influenza crises, governmental capacity in infectious disease control was the strongest in Singapore, followed in order of effectiveness by Hong Kong, South Korea, Vietnam, China, and Taiwan. In November 2006, South Korea took immediate action to slaughter 125 000 chickens, and 236 000 poultry as well as pigs, dogs, and cats during the outbreak of H5N1.13 Vietnam was viewed as a successful example of containing its spread in 2003. However, its success should not be exaggerated: due to the small number of SARS cases, Hanoi could contain the virus by adopting a tight monitoring system. It remains to be seen whether Vietnam can contain the spread of avian influenza. In fact, chickens smuggled from China to Vietnam carry the danger of transmitting H5N1 across the border.14 With an increase in human traffic and trade flows across the Sino-Vietnamese border, infectious disease can penetrate Vietnam rapidly but invisibly. China’s response to SARS was divided into two phases, including an earlier stage in which a sluggish response was compounded by localism and a later stage where leadership from the top was intertwined with full-scale mobilisation of the public
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to combat SARS. Although Taiwan is politically democratic, its capacity in disease control turned out to be weak. On average in 2006, a nurse in Taiwan had to take care of 20 to 30 patients and there was total shortage of 20 000 nurses.15 The relatively underdeveloped healthcare system and the lack of an effective surveillance system in mainland China and Hong Kong render Taiwan an isolated island under the threat of any influenza epidemic. Although informal interactions between health workers in all three places continue, it is hoped that formal discussions on infectious disease control can be developed and enhanced in the near future so that South China as a whole will collectively strengthen its capacity of dealing with any regional health crisis. Macao remains untested in its governmental capacity to tackle SARS. Surprisingly, it did not have a single case of SARS. However, non-respiratory infectious diseases such as dengue fever occasionally broke out in 2003. The Macao government swiftly contained the dengue fever, thanks to its network of neighbourhood associations that successfully acted not only as an effective intermediary between the government and its citizens but also as a mobilising vehicle against mosquitoes, which carry the disease. Whenever cases of avian influenza have broken out in China, the Macao government dispatches officials to visit the mainland and look into the situation.16 In early 2008, when the mysterious influenza affected some schoolchildren in Hong Kong, Macao was on high alert and prepared for a similar outbreak in the territory. Vigilance has become a critical factor shaping Macao’s health governance. Implications for Canada: Difficult Choices Ahead The varying degrees of preparedness, openness, and responsiveness of Asian governments in handling of infectious disease have implications for Canada. Canadian preparedness in anticipation of an influenza epidemic remains insufficient. A gap exists between the health elites, who appear to be more prepared, and the citizens, who are relatively unprepared. An indispensable ingredient of preparedness is crisis consciousness. Surprisingly, even after the SARS crisis, a majority of Canadians appear to treat the influenza epidemic as a non-issue, at least in the short run. None of the candidates who participated in Ontario’s municipal and mayoral elections in November 2006 raised the issue of how the province should tackle any outbreak of the influenza pandemic. The Ontario municipal elections in October 2007 also ignored the issue. The question of the influenza pandemic was virtually absent in public debates and candidates’ platforms. When schoolchildren in Hong Kong died in early 2008, apart from the Chinese-Canadian press and some electronic media outlets, the Canadian media were uninterested. As hundreds of thousands of overseas Chinese reside in Canada’s major cities, and as many of them travel frequently between Hong Kong and Canada, Canadian health officials must maintain a vigilant attitude toward any outbreak of influenza in South China. Canadian mainstream media, which tend to display a North American and European bias in their news coverage, should cover more Asian news, especially the ongoing health developments that affect Canadians swiftly.
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The Canadian Influenza Pandemic Plan does illustrate the high degree of governmental preparedness at the federal level. Yet the plan merely ‘encourages’ provincial and municipal governments to educate citizens on the influenza crisis. The federal government thus has shifted the responsibility for education and publicity to the provincial and local governments. Except for the occasional television and newspapers advertisements on influenza shots, publicity on the influenza pandemic has remained very weak. Perhaps the provincial and municipal governments wish to avoid creating any unnecessary public panic. Nonetheless, more publicity on the influenza pandemic would heighten the crisis consciousness of most Canadians, in addition to educating them on the need to wash their hands frequently to protect against any influenza virus. It would also deepen the public’s understanding of how it would be mobilised in the event of an epidemic, which is imperative. The updated Canadian Pandemic Influenza Plan for the Health Sector has put forward detailed recommendations to strengthen preparedness, including surveillance, vaccines, antivirals, health service emergency planning, public health measures, and communications (PHAC 2006). The plan mentions the creation of the Health Emergency Communications Network to improve federal and provincial interactions in response to the SARS, and the formation of a communications sub-committee, but it remains unclear how these bodies coordinate with each other. From a critical perspective, additional layers of bureaucracy appear to be an effective remedy; nonetheless, the actual operations of these committees will have to be reviewed and tested in simulation exercises. Otherwise, bureaucratisation in the form of setting up new agencies may not guarantee a significant improvement in intergovernmental communications and overall governmental preparedness for a new epidemic. The example of Hong Kong’s chaotic hospital response to SARS proved that interdepartmental coordination was critical to an effective response. The plan sets out the National Emergency Response System, which involves interactions between the prime minister and the provincial premiers, between the Cabinet Committee for Security, Public Health, and Emergencies and provincial ministers, and between federal deputy ministers and their provincial counterparts (PHAC 2006, annex L). However, the vertical chain of command remains long and complicated. This bureaucratised approach raises two serious questions: whether the line of accountability will be clear to all actors and whether it will generate a cumbersome process unintentionally detrimental to a swift crisis response. It is doubtful whether the updated plan can significantly ameliorate Canada’s preparedness and response to any new epidemic. Furthermore, while Canadian society is far more open or transparent than many Asian states, Canadian mass media generally have up to now been insufficiently interested in probing influenza pandemics. Perhaps the mass media at the national, provincial, and local levels have been preoccupied with other salient issues, such as politics, Canada’s involvement in Afghanistan, Quebec’s status, transport, crime, education, the environment, and tax issues. Ironically Canada is endowed with highly sophisticated mass media, but they have not yet developed an inquisitiveness in investigating the many issues surrounding any imminent influenza pandemic,
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especially public preparedness and governmental responsiveness. If crisis consciousness and preparedness are weak in Canada, responsiveness becomes the most critical variable the shape the Canadian government’s capacity to control any influenza pandemic. The Asian response has an important bearing on Canada. Singapore’s swift response to enforce a strict quarantine of people suspected of having SARS in safe houses deserves Canadian attention. Critics must question whether the Singapore model jeopardised the individual rights of SARS-infected victims. Arguably, centralisation and perhaps authoritarianism are necessary in any swift governmental response to infectious disease. Tight surveillance of the SARS victims, who were put in solitary confinement, constituted an effective deterrent to further infection. Unlike Hong Kong, where individual rights were emphasised in a way that may have endangered public safety during the outbreak, the Singapore government was free from the political burden of protecting individual rights in the fight against SARS. In Hong Kong, where the business sector was concerned about the impact of border control on the economy; by contrast Singaporean business did not constrain the governmental handling of the crisis. The Singaporean experience pointed to the tremendous state power and unified societal forces that could be galvanised to prevent the spread of infectious disease. In a small city like Singapore, administrative centralisation and political authoritarianism are virtues in preventing the population from being wiped out during the outbreak of a rapidly transmitted infectious disease. Authoritarianism is usually denounced by liberal academics as undesirable in the process of western-style democratisation, but it is the most effective response against the encroachment of an influenza pandemic. However, the Singapore model is not applicable to Canada. The argument that authoritarianism is necessary is surely unacceptable to most Canadians, who champion individual liberties. If an influenza pandemic takes place in Canada, it is very doubtful whether the public will reach a consensus on any swift action by the Canadian government to contain it. Any strict quarantine measure through forced segregation would be easily seen as a violation of individual rights. Trade unions, which have been traditionally powerful in Canada, would likely object to measures that would quarantine their members. It remains doubtful whether healthcare workers’ unions would support the Canadian government’s emergency measures during an outbreak. Business groups would likely argue against temporarily closing the border with Asia, not to mention with the United States, because they perceive border security measures as detrimental to trade and commerce. As in Hong Kong, where the procapitalist and pro-business government hesitated to impose border control prior to the apex of SARS because of its fear of any adverse economic impact, Canada’s capitalist state would most likely encounter very difficult choices in the event of an influenza pandemic, although it too would be anxious about negative impacts. Provincially and locally, there would most probably be a fragmentation of elite opinion, including both politicians and businesspeople, on the scope of border control measures, thus complicating the federal government’s decisions. Yet the
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experience of Hong Kong and Singapore in the SARS crisis demonstrated that at a critical juncture, their governments had to impose border control measures, enforce strict quarantine, and forbid the arrival of air flights from infected areas. These measures would be very difficult to implement in Canada if vociferous trade unions, influential business chambers, and opposition politicians were squabbling with the governments at the federal and provincial levels. At a particular juncture where infectious disease entails human-to-human transmission, the Canadian government would have to evoke emergency regulations, applied to federal, provincial, and municipal levels, so that decisive actions would be legalised to stem the inflow and outflow of an influenza pandemic.17 Ideally, the House of Commons would pass a motion in support of the government’s decision to declare a national emergency. Internal national security would be of paramount importance to Canada regardless of how the critics would react to decisive measures. A significant potential danger during an outbreak would be the precedence given democratic rights over national security. At a critical juncture, all Canadians, including opposition parties, business groups, and trade unions, must be united in supporting whatever measures are adopted by governments at all levels to combat the onslaught of the influenza pandemic. It is tempting to argue that any democratic regime has to strike a balance between democratic rights and national security in the event of a pandemic. As with the fight against terrorism, western states have been under severe criticism for trampling individual rights for the sake of protecting themselves against terrorist attacks. An influenza pandemic is tantamount to biological terrorism. In response, decisiveness and authoritarianism would thus be the sine qua non to contain deadly infectious disease. If, for example, a lottery system is proposed as a way to decide who would receive vaccines instead of determining a priority list of citizens, the Canadian government’s capacity would be severely curtailed. Such a lottery system would generate governmental clumsiness. Fairness must be observed in the governmental treatment of citizens receiving vaccines, because citizens at the lower end of the priority list might be treated later. Groups and individuals ought to be allowed to voice their views freely, but such views should not usurp the authoritative power of the government to allocate resources in times of crisis. Governmental capacity, which also embraces the freedom to distribute resources and mobilise human resources, will have to be maintained. Canadians will have to appreciate that any influenza pandemic would be comparable to another world war, instead of thinking of it as SARS-type mayhem on a grander scale. As with the Asian situation, Canada’s governmental capacity in disease control will be shaped by political leadership. Hong Kong’s response to the SARS crisis revealed serious problems in departmental coordination, especially in communications between the Department of Health and the Hospital Authority.18 When the authorities at the Prince of Wales Hospital planned to close the entire emergency ward to prevent any members of the community from being infected, the health department held a different view. The case of Hong Kong demonstrated that
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a fragmented health system without sufficient communication and decisive political leadership could have catastrophic consequences. The implications for Canada are obvious. Health Canada would have to communicate with all hospitals intensively and accurately. Provincial health authorities must frequently coordinate with their federal counterparts, and local health officials would need to report accurately on the health circumstances and statistics to municipal governments. Given the three levels of government in Canada, coordination and communication will surely become complicated. Here, simulation exercises are particularly needed to test the channels of communication between federal and provincial health authorities and between municipal and provincial health officials. Timing is also a problem that requires political leadership. When the HKSAR government under C.H. Tung considered installing infra-red temperature-testing equipment at various border checkpoints, it would have taken at least a week to buy, prepare, test, and install the sophisticated detectors. Critics said that the government should have made that decision much earlier. Before the HKSAR government decided to implement temperature tests on all primary and secondary schoolchildren, it had hesitated until parents complained vociferously about the safety of their children.19 The timing of all decisions relating to infectious disease will be a similarly huge challenge to Canada’s federal, provincial, and municipal governments. Canada’s healthcare system, like Taiwan’s, lacks enough doctors and nurses. This shortage in Canada must be addressed urgently. In the event of a pandemic, there would inevitably be a gradual attrition of hospital staff. Some workers would succumb to the virulent infectious disease, as happened with SARS. To replenish the loss, Canada would have to mobilise reserve workers, including medical students and all immigrants with healthcare backgrounds. The Canadian government at both the federal and the provincial levels must accelerate the process of recognising the medical qualifications of its large pool of immigrants, whose skills should be fully available in their new and permanent Canadian home, especially in a crisis situation. Canada can also learn from Hong Kong that its health system can be consolidated by privatising healthcare delivery so that the federal and provincial governments would have more available resources. These resources could be allocated to increasing the pay of hospital staff, supplementing human resources by matching immigrants with the markets that need their skills, and improving coordination among all the hospitals and the provincial and municipal governments.
Toward a 20-Point Action Plan for Canada An unknown variable affecting Canada and the world is, of course, the length of any influenza pandemic. While this factor is perhaps uncontrollable, both the private and public sectors can take preventive measures to tackle the influenza pandemic. Here a 20-point action plan is appropriate.
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First, all Canadian companies should test their emergency plans. The Canadian Manufacturers and Exporters (CME) have assisted various corporations in formulating such plans to respond to an influenza pandemic. They produced an impressive 20-point checklist, including identifying a manager responsible for the pandemic plan, determining the pandemic’s financial impact, building confidence among employees, preparing for an absenteeism rate of 35 percent to 50 percent during a two-week peak period, and appealing to all companies to test and share their plans with the government (CME 2006). However, the number of companies that have shared their influenza pandemic plans with the local governments is unknown. In a sudden influenza crisis, the impact on Canadian business would perhaps be much larger if there were no simulation exercise with regard to the influenza pandemic plan prepared by various companies. Second, governmental communication with poultry workers and farmers must be enhanced. They have already been alerted to the likelihood of the outbreak of avian influenza. The Chicken Farmers of Ontario vowed to try its best to prevent the spread of any avian influenza from farms to the community. During an avian influenza pandemic, it would be critical to know how to separate locally produced poultry from imported poultry. If the local farms were safeguarded against the crisis, the extent to which they could continue to supply food would need constant assessment, necessitating a partnership between agricultural and health officials on the one hand and farmers on the other. Third, in the event of an influenza pandemic, it is unclear how pets would be managed at the provincial and municipal levels. Ideally, pets would have to be segregated to prevent human beings from being infected more easily. Yet such segregation would arouse the opposition of pet owners. A moderate solution is to encourage them to have their pets undergo voluntary quarantine and medical checkups. During the peak of an influenza pandemic, tougher measures may have to be considered. Any emergency regulation by the federal government to deal with an influenza pandemic must incorporate pet management so that provincial and territorial governments would be legally empowered to act as needed. Fourth, it is estimated that there are 200 000 illegal immigrants in Canada (Keung 2006). Their fate and possible access to health care would become critical issues in the event of the influenza pandemic, because they tend to be afraid of visiting the doctors for fear of being deported. Yet urgent medical care would have to be provided to this underground population, who would be required to register with the authorities. A partial amnesty may be required; otherwise, illegal immigrants without access to healthcare services would become an extremely vulnerable segment of the society. The federal government must collaborate with the provincial governments on the future of illegal immigrants, whose susceptibility to an influenza outbreak would directly or indirectly affect the death toll in Canada. Fifth, during the high tide of an influenza pandemic, Canadian citizens residing overseas who return to Canada may have to be segregated into camps remote from urban communities. The idea is not to discriminate against them, but to provide safeguards against the likelihood of any returnees who may be infected with the
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influenza virus. Indeed, the question of evacuating Canadian citizens from places where an influenza pandemic has erupted would be a tricky one. Hong Kong would surely become a place necessitating emergency planning due to the 250 000 Canadian citizens residing there. The 1.2 million Canadians in the United States would also call for special policy consideration. If evacuation were implemented, the spread of the virus could be facilitated practically, but if it were discouraged, then returned Canadians may be quarantined at a relatively remote place for a certain period. During the SARS outbreak, 13 000 Torontonians who travelled to infected areas quarantined themselves voluntarily for several days to prevent others from possibly being infected, but such a self-driven initiative would have a very limited impact in the event of an influenza pandemic.20 Police efforts to track down the whereabouts of travellers who returned to Canada from affected places would be insufficient during a pandemic unless all returnees were temporarily quarantined in safe houses. Sixth, at the apex of the influenza pandemic, all schools in Canada should be closed, thus disrupting the studies of hundreds of thousands of children. Kindergarten, elementary schools, high schools, and universities would have to terminate their classes, affecting teaching and research on an unimaginable scale. Each school should be required to test its emergency plan at least once per year. There should be a plan in place to continue classes using email and internet facilities. Otherwise, a lack of preparedness would generate massive panic and frustration at the grassroots level. Seventh, the health authorities should regulate the sale of anti-influenza drugs and vaccines to prevent their sale through illicit channels including the internet. During a pandemic, criminal elements may take advantage of the crisis to sell sub-standard vaccines and drugs through various means. Similarly, the promise of Tamiflu could trigger criminal syndicates to produce fake antiviral drugs.21 Eighth, at the apex of the influenza crisis, the borders with Asia, Africa, Europe, the United States, and other parts of the world would have to be temporarily closed to prevent the virus from being transmitted further afield. Yet this measure would have calamitous consequences on the domestic economy and transportation industries. Air and ground transport, so crucial in this globalised era, would have to be temporarily suspended. Critics have already questioned the effectiveness of an air travel ban. Ninth, the already strained staffing situation in hospitals would mean that health workers would endure even more stressful work conditions. But the government would have to solicit their unreserved support. Complaints about any public maladministration of hospitals could arise, ranging from inadequate masks to insufficiently strict quarantine measures for influenza-infected patients. Effective hospital management would constitute the determining factor shaping Canada’s resistance to the influenza epidemic. Tenth, quarantine measures must be modified and adapted to the circumstances. The Singaporean model of using cell phones and video conferencing for communications between patients and their families should be considered. Family members must be persuaded of the complexities of the infectious disease. Without widespread public education, a sudden influenza pandemic would likely split society. Some observers have rightly noted that the Canadian government needs
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a more assertive publicity campaign so the public better comprehends the origins, complexities, and consequences of any influenza pandemic.22 Eleventh, a large-scale educational campaign should be launched to increase the crisis consciousness of all Canadians about any influenza pandemic. In the event of such a crisis, some ethnic communities would become inactive, forcing citizens to stay home and suffer from the psychological impact of reported deaths among their communities, especially in Vancouver and Toronto where there are large numbers of immigrants. In the worst-case scenario, members of some ethnic groups would run the risk of being stereotyped as ‘undesirable’ virus carriers due to the origin of the influenza pandemic in their ‘home countries’, even though they may have long treated Canada as their permanent homes.23 Racial discrimination would unfortunately re-emerge, making ethnic groups point their accusing fingers at others. Unless Canadian governments at all levels launch an appropriate, extensive education campaign for all citizens, ethnic misunderstandings could be a time bomb undermining Canada’s social harmony. In the event that most members of the public remain complacent, their relative lack of preparedness would render social mobilisation against the spread of an influenza pandemic difficult and time consuming. Educating the public extensively about a pandemic does not create panic. Instead, it paves the way for social unity and mobilisation during a crisis. Twelfth, the Canadian government must rigorously augment its reserves of antiinfluenza vaccines, which have already been increased from 16 million shots to 50 million shots.24 The stockpiles must be consolidated if Canada is to construct an effective shield against an influenza pandemic. Thirteenth, in light of the fact that many hospitals in China had their windows open to improve air circulation during the SARS crisis, the Canadian government must ensure that the ventilation system of public hospitals, government buildings, and all other public places is frequently inspected and cleaned. Due to the weather conditions in Canada, many hospital and buildings have their windows tightly closed, a phenomenon that could increase the transmission of infectious disease. The outbreak of Legionnaires’ disease in the Seven Oaks Home for the Aged in Toronto in 2005 revealed the problematic ventilation system in some Canadian hospitals. Fourteenth, municipal governments need a two-pronged strategy to educate the public on the influenza pandemic and to improve their capacity. It is reported that Toronto would not have the ability to cope with a large-scale influenza pandemic, that 2.6 million citizens would be unable to receive timely vaccinations, and that 35 percent of the population of Ontario would be infected with the influenza virus.25 Municipal leaders should be required to conduct exercises to enhance their influenza management capacity. An auspicious sign is that many municipal regions, such as Ontario’s Peel and York regions, have formulated emergency plans to cope with infectious disease such as an influenza pandemic and the West Nile virus.26 Nevertheless, simulation exercises must be carried out to improve municipal preparedness. Fifteenth, since Canada is endowed with a vast physical space, it has tremendous potential to develop makeshift hospitals, quarantine camps, and special funeral
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services to tackle an influenza pandemic. Municipal governments must identify specific sites for public cemeteries to dispose of the bodies of influenza victims. Corpse management will require technical details that must be hammered out between the funeral service specialists and health officials. Canada should take full advantage of its physical vastness to cope with any influenza pandemic. Sixteenth, Canada’s airports must consider emergency measures, such as the installation of infra-red temperature-testing detectors and detailed recording of passengers’ personal data, including addresses and final destinations in Canada. While it would be costly for all airports to instal the equipment, airports in all cities, especially Vancouver, Toronto, Ottawa, and Montreal, will need temperaturetesting equipment, and any airport with international flights and connections to other Canadian cities would need tighter measures against an influenza pandemic. Seventeenth, all public-private partnerships should require their private sector partners to test their emergency plans. A simulation exercise that takes several hours involves minimal economic costs but will equip more Canadians with the basic skills necessary to ward off any national health crisis. Eighteenth, simulation exercises must be conducted involving the federal and provincial governments, as well as each provincial or territorial government and its municipalities and each municipal administration and local communities. Ontario and British Columbia have published their emergency influenza pandemic plans in detail, but Nunavut appears to lack a sophisticated plan on its website.27 Quebec provides comprehensive and elaborate structure on the specific agencies responsible for coordination and communication. A careful reading of the websites shows that not all provinces or territories agree on the definitions of coordination and communication, with some stressing the interprovincial dimension and others showing a more balanced view of internal departmental cooperation and federalprovincial partnerships. Perhaps due to the province’s experience with SARS, Ontario’s plan mentions the need for media conferences, video-conferences, and teleconferencing interactions with public health officials. The discrepancies in provincial plans demonstrate their varying cultures and attitudes in response to the danger of any influenza pandemic. Nineteenth, Canadians in general are complacent and relatively relaxed about the likelihood of an influenza pandemic. This attitude must change. More nationwide publicity must educate the public on coping with an influenza pandemic and increase awareness of how to respond to an abrupt crisis. While multiculturalism is usually hailed as a strength in Canada’s political system and social mosaic, the country’s diversified cultural groups must be made aware of how to act collectively in the event of something as serious as a pandemic outbreak or, for that matter, a bio-terrorist attack. Otherwise the eruption of an influenza pandemic could plunge Canadian society and its governments into turbulence. Twentieth, officials of the Canadian federal government must become more sensitive to a possible influenza crisis. Canada needs to discuss emergency planning with the United States, particularly with regard to border controls in the event of an influenza pandemic.28 Moreover, Canada’s official representatives in Asia must
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enhance their information-gathering activities with regard to the development of infectious disease. Equipped with updated information provided by the Canadian consular and embassy officials in Asia, Ottawa can draw an accurate picture of the ongoing development of avian influenza in the Asia Pacific region.
Conclusion A crucial indicator of effective health governance is the ability of a city or state to cope with a public health crisis, especially one involving respiratory infectious diseases. Canada has much to learn from the bitter lessons of SARS and the ways in which Singapore and Hong Kong dealt with SARS. Being a democracy does not necessarily mean that a country’s federal and sub-federal governments have the capacity to control the influenza pandemic effectively. Governmental decisiveness during any influenza pandemic is far more important than the protection of civil liberties. Coordination among government departments at all levels is a critical variable in shaping the Canadian government’s response to an influenza pandemic. Emergency regulations must be enacted by the House of Commons so that Canadians will remain united across the country to fight against the attack. Provincial differences in Canada have already revealed the varying emphases on how provincial governments perceive an influenza pandemic. Yet if Canada’s governments at the federal, provincial, and municipal levels, together with the private sector, implement the 20-point action plan proposed in this chapter, the country’s governmental capacity for managing an influenza pandemic would be substantially enhanced. Canadians must not be complacent. Detailed pandemic preparedness plans may have been published, but serious questions remain about governmental coordination, public education, crisis consciousness, and social mobilisation, and these issues are critical to the effective health governance, public safety and national security of all Canadians.
Notes 1 This is a revised version of a research project of the Asia Pacific Foundation of Canada. 2 On Asia’s vulnerability during the SARS outbreak, see Caballero-Anthony (2005). 3 In Singapore people exposed to SARS were required to stay home, were watched by a camera, and sometimes were tagged with an electronic wristband. They could be imprisoned if they left home (‘Singapore’s SARS Measures Welcome’ 2003). The Singapore police not only tested the temperature of those quarantined twice daily but also set up a temporary lock-up centre at the old Jurong Police Station to deal with suspected SARS carriers (‘Police Take Precautionary Measures against SARS’ 2003; see also Fung 2003). Unlike Hong Kong, where schools were closed after much governmental hesitation, the Singaporean government moved decisively to close nearly all schools on 25 March, mainly due to the concern of parents. 4 For the view that Singapore is an authoritarian polity, see Rodan (2005). An opposite view can be found in Bellows (2006).
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5 For Chan’s controversial remarks during the avian influenza crisis in 1997, see World Journal, 10 November 2006, A21; see also Richburg (1998). 6 Ming Pao, 9 November 2006, A15. 7 Strait Times, 30 April 2003. 8 Sing Tao Daily, 24 May 2006, B15. An Austrian journalists association complained that Taiwan journalists were barred from covering the WHO meeting because the WHO said that Taiwan was not a member of the United Nations. 9 Ming Pao, 11 March 2006, A11. 10 In 2005, a Conservative member of Canada’s Parliament initiated a private member’s bill that supported Taiwan’s participation in international the WHO, which was approved by the Foreign Affairs Committee in the House of Commons. World Journal, 20 May 2006, A7 (see also Standing Committee on Foreign Affairs and International Trade 2005). A joint letter was signed by 151 members of House of Commons and the Senate to appeal to the WHO to accept Taiwan as an observer because the outbreak of any influenza pandemic there would severely affect Canada, which has about 150 000 citizens visiting Canada every year. For the American support of Taiwan, see Ming Pao, 20 May 2006, A25. 11 ‘Chan Praises Healthy Cooperation’, China Daily, 28 November 2006. 12 Chan is a Canadian citizen who holds a doctorate in medicine from the University of Western Ontario. 13 ‘South Korea to Kill Cats, Dogs over Flu Fears’, Associated Press, 27 November 2006. Some critics said that South Korea overreacted. 14 In 2006 30 smuggled chickens from China to Vietnam were found to have H5 virus. Ming Pao, 7 April 2006, A11. 15 United Daily Evening News (Taiwan), March 30, 2006, cited in Today Daily News, March 31, 2006, p. B10. 16 When avian influenza broke out in Guangdong in March 2006, Macao officials went to Zhongshan and Zhuhai to inspect the situation. TVB News, 7 March 2006. 17 The executive summary of Learning from SARS, the report of the National Advisory Committee on SARS and Public Health (2003b), pinpoints that ‘the F/P/T [federal/ provincial/territorial] legislative frameworks for health emergencies have not been analyzed for comparability and interoperability’. 18 A useful review of how the Hong Kong government coped with the SARS crisis can be found in Loh (2004, 117–138). 19 The author wrote a commentary in Ming Pao advocating that the HKSAR government should close the schools, after which he received a phone call from a parent saying that his demand echoed the views of many worried parents. 20 Sing Tao Daily, 19 April 2006, A12. 21 In 2006, fake anti-influenza vaccines were found in China and Hong Kong. It is noteworthy that Tamiflu was reported to be linked to neurological disorders in a few cases. 22 Harris Ali has accurately observed that compared to publicity campaigns in Hong Kong and Singapore, Canada lags behind in terms of appealing to citizens to wash their hands frequently, avoid contacts with birds, and shun the practice of feeding birds. Ming Pao, 19 April 2006, A4. 23 Some members of the Chinese community felt that during the SARS outbreak the Canadian Chinese in Toronto were unfairly labelled by other Canadians as potential virus carriers. 24 Ming Pao, 14 May 2006, A8. 25 Today Daily News, 16 April 2006, A4.
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26 Ming Pao, 15 April 2006, p. A2, and Sing Tao Daily, 29 May 2006, A8. Some other municipalities have pandemic-related information on their websites. The Ontario city of Waterloo, for example, updates its website from time to time. It was estimated that in the worst-case scenario, 127 000 people in the Waterloo region would need outpatient care; up to 2400 would have to be hospitalised and 700 would die (Kelly 2006). 27 See ‘Pandemic Influenza’ at <www.influenza.gc.ca>. 28 The U.S. has been deeply concerned about the development of avian influenza in Asia, conducting a close surveillance of the routes of migratory birds, banning the import of chicken from China in May 2006 when the PRC had cases of avian influenza, and stockpiling Tamiflu in preparation for the influenza pandemic. Ming Pao, 2 March 2006, A11, and 4 May 2006, A10; World Journal, 14 April 2006, A2.
References Bellows, Thomas (2006). ‘Economic Challenges and Political Innovation: The Case of Singapore.’ Asian Affairs, vol. 32, no. 4, pp. 231–255. ‘Bird Flu Strikes Again in Thailand.’ (2007). Scientific American, 2 February. Bonn, Dorothy (2003). ‘Closing In on the Cause of SARS.’ Lancet Infectious Diseases, vol. 3, no. 5, p. 268. Bugl, Paul (2007). ‘Review of SARS in Context: Memory, History, Policy.’ Lancet Infectious Diseases, vol. 7, p. 710. Caballero-Anthony, Mely (2005). ‘SARS in Asia: Crisis, Vulnerabilities, and Regional Responses.’ Asian Survey, vol. 45, no. 3, pp. 475–495. Canadian Manufacturers and Exporters (2006). Influenza Pandemic: Continuity Planning Guide for Canadian Business. Ottawa. <www.cme-mec.ca/pdf/CME_Pandemic_Guide. pdf> (September 2008). Fung, Alan (2003). ‘SARS: How Singapore Outmanaged the Others.’ Asia Times, 9 April. <www.atimes.com/atimes/China/ED09Ad03.html> (September 2008). Garrett, Laurie (2005). ‘The Next Pandemic?’ Foreign Affairs, vol. 84, no. 4, pp. 3–13. <www.foreignaffairs.org/20050701faessay84401/laurie-garrett/the-next-pandemic.html> (September 2008). Greger, Michael (2006). Bird Flu: A Virus of Our Own Hatching. (Herndon VA: Lantern Books) (September 2008). Kelly, Anne (2006). ‘Region Sets Up Pandemic Website.’ Record (Kitchener-Waterloo), 28 April, p. B2. Keung, Nicholas (2006). ‘Illegals Afraid to See a Doctor.’ Toronto Star, 23 May, p. A4. Legislative Council of the Hong Kong Special Administrative Region (2006). Report on the Duty Visit to Study the Operation of Poultry Slaughtering in Singapore. LC Paper No. CB(2)3134/05-06. <www.legco.gov.hk/yr05-06/english/hc/papers/hc1006cb2-3134-e. pdf> (September 2008). Loh, Christine and Civic Exchange, eds. (2004). At the Epicentre: Hong Kong and the SARS Outbreak. (Hong Kong: Hong Kong University Press). Monto, Arnold S. (2005). ‘The Threat of an Avian Influenza Pandemic.’ New England Journal of Medicine, vol. 352, no. 4, pp. 323–325. National Advisory Committee on SARS and Public Health (2003a). 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).
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National Advisory Committee on SARS and Public Health (2003b). Learning from SARS: Renewal of Public Health in Canada—Executive Summary. Chaired by David Naylor. Ottawa. <www.phac-aspc.gc.ca/publicat/sars-sras/naylor/exec-eng.php> (September 2008). 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). Paterson, Rachel (2004). ‘SARS Returns to China.’ Lancet Infectious Diseases, vol. 4, no. 2, p. 64. ‘Police Take Precautionary Measures against SARS.’ (2003). Strait Times, 29 April. Public Health Agency of Canada (2004). Canadian Pandemic Influenza Plan. Ottawa. (September 2008). Public Health Agency of Canada (2006). The Canadian Pandemic Influenza Plan for the Health Sector. Ottawa. <www.phac-aspc.gc.ca/cpip-pclcpi> (September 2008). Revill, Jo (2005). Everything You Need to Know about Bird Flu and What You Can Do to Prepare for It. (London: Rodale). Richburg, Keith B. (1998). ‘Hong Kong Faulted on Handling of “Bird Flu” Crisis.’ Washington Post, 4 January, p. A17. <www.washingtonpost.com/wp-srv/inatl/longterm/china/stories/ kong010498.htm> (September 2008). Rodan, Garry (2005). ‘Embracing Electronic Media but Suppressing Civil Society: Authoritarian Consolidation in Singapore.’ Pacific Review, vol. 18, no. 3, pp. 393–415. Saich, Tony (2006). ‘Is SARS China’s Chernobyl or Much Ado about Nothing?’ In A. Kleinman and J.L. Watson, eds., SARS in China: Prelude to Pandemic?, pp. 71–104 (Stanford: Stanford University Press). ‘Singapore’s SARS Measures Welcome.’ (2003). New York Times, 22 April. Standing Committee on Foreign Affairs and International Trade (2005). Evidence. 6 October, No. 055, First Session. Ottawa. (September 2008). Thomson, Elspeth and Yow Cheun Hoe (2004). ‘The Hong Kong SAR Government, Civil Society, and SARS.’ In J. Wong, ed., Zheng, Yongnian, pp. 199–220 (Singapore: World Scientific). Ungchusak, Kumnuan, Prasert Auewarakul, Scott F. Dowell, et al. (2005). ‘Probable Personto-Person Transmission of Avian Influenza A (H5N1).’ New England Journal of Medicine, vol. 352, no. 4, pp. 333–340. World Health Organization (2004a). ‘Avian Influenza: Fact Sheet.’ 15 January. Geneva. <www.who.int/csr/don/2004_01_15/en> (June 2006). World Health Organization (2004b). ‘Summary of Probable SARS Cases with Onset of Illness from 1 November 2002 to 31 July 2003.’ 21 April. Geneva. <www.who.int/csr/ sars/country/table2004_04_21/en> (September 2008). Zhang, Ernest and Kenneth Fleming (2005). ‘Examination of Characteristics of New Media under Censorship: A Content Analysis of Selected Chinese Newspapers’ SARS Coverage.’ Asian Journal of Communication, vol. 15, no. 3, pp. 319–339.
Chapter 6
The Role of Civil Society in Pandemic Preparedness Kathryn White and Maria Banda1
Today, in an interconnected world, bacteria and viruses travel almost as fast as e-mail and financial flows. Globalization has connected Bujumbura to Bombay and Bangkok to Boston. There are no health sanctuaries. No impregnable walls exist between a world that is healthy, well-fed, and well-off and another that is sick, malnourished, and impoverished. Globalization has shrunk distances, broken down old barriers, and linked people. Problems halfway around the world become everyone’s problem. —Gro Harlem Brundtland, former director general, World Health Organization The rise of civil society is indeed one of the landmark events of our times. Global governance is no longer the sole domain of Governments. The growing participation and influence of non-State actors is enhancing democracy and reshaping multilateralism. Civil society organizations are also the prime movers of some of the most innovative initiatives to deal with emerging global threats. —Fernando Henrique Cardoso, chair of the United Nations Panel of Eminent Persons on the United Nations–Civil Society Relations This chapter sets out a framework by which civil society actors can identify their role in preparing for, mitigating, and confronting one particular international threat, namely avian influenza. Governments and multilateral organisations have recognised the need to work with civil society across a range of issues. For example, in response to avian influenza and its alarming human mortality rate, as well as the resulting crosssectoral economic and societal damage, in October 2005 the Canadian government convened a meeting of 30 health ministers in an attempt to coordinate transnational planning and response. At the same time, the United Nations Association in Canada (UNAC) called for the full engagement of civil society in this critical dialogue. The chapter is in fact an example of knowledge transfer among the civil society organisations, governments, multilateral organisations, the private sector, and, ultimately, citizens who must be ready, able, and trusted to slow the next threat.2 Civil society organisations range from strong international groups with their own health, agriculture, and security experts to volunteer-based groups that are much closer to the ground and focussed on protecting their communities. As such, civil
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society organisations have historically undertaken both grassroots work and highlevel advocacy. This chapter aims to encourage civil society—and its partners—to identify issues, challenges, and opportunities they would face in preparing, planning, and engaging in such a crisis. In 2005 when the Canadian government and the UNAC were working on the issue of avian influenza, all signs were ominously suggesting that a pandemic of proportions not witnessed since the Spanish influenza of 1918 was imminent (World Health Organization [WHO] 2005; Osterholm 2005). But this time the world had an opportunity to defend itself before the pandemic struck.3 Once the alarm bells had gone off in the public health community, it was time for a more reflective analysis on the part of civil society about its responsibilities and role in pandemic preparedness planning. Civil society, as defined by the Panel of Eminent Persons on United Nations–Civil Society Relations (2004, 13), spans voluntary associations of citizens (outside their families, friends, and businesses) formed to ‘advance their interests, ideas and ideologies’. It includes groups as diverse as mass organisations (for example, farmers, women, seniors), trade unions, professional associations, social movements, indigenous people’s assemblies, faith-based organisations, academe, and nongovernmental organisations (NGOs) devoted to environment, development, human rights, and peace. It is easy to see the tremendous source of ingenuity, cooperation, and innovation that could be tapped by activating and engaging such a transnational network. The UN has recognised that the achievement of the health-related Millennium Development Goals (MDGs) and other global objectives will depend on a collaborative approach made possible through civil society partnerships (UN Secretary General 2002). Before harnessing the global civic actor’s latent power across the multitude of its activities, a greater understanding of the social determinants and securitisation of health is needed. Avian influenza presents interrelated economic, agricultural, security, developmental, and ecological challenges; therefore, the approach to the looming pandemic must take an equally integrated, cross-sectoral, cross-regional perspective in order to develop a common platform of understanding among stakeholders. Although the threat of avian influenza in 2005 represents one specific crisis scenario, it can be placed within a broader context of a global healthcare crisis, poverty, insecurity, and environmental degradation. A survey of how all of these issues feed into the pandemic potential clearly reveals the need for a comprehensive, sustained, multidimensional—and multilateral—strategy. With common challenges and shared responsibilities inherent in fighting an infectious disease in the age of globalisation, it is necessary to catalyse complementary actions beyond the health sector’s existing services and programmes. The first part of this chapter thus follows the virus on its whirlwind track since 1996 as it travelled across Eurasia and made a brief foray into Canada in the spring of 2004. The second part discusses the global public health architecture and looks in particular at the role of civil society in institution building. The third part shifts the focus from the structures, participants, and processes of governance to its
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negotiations agenda and substantive issues. The fourth part summarises the main intellectual approaches to infectious disease control, from which it distils the best practices in order to propose a new integrated model of transnational, multi-actor governance. Raising public awareness is one effective way to promote appropriate health and agriculture actions, especially if it engages at-risk communities and sectors in developing responses and solutions. All too often ‘indifference becomes fear only after catastrophe hits, when it is already too late to implement preventive or control measures’ (Osterholm 2005). The next pandemic is overdue and inevitable (WHO 2005). The only question is whether an institution sturdy enough to withstand its lethal blow will be built in time. The Global Evolution of Avian Influenza Globalisation has made the world a smaller place, but it has also made humanity more vulnerable to microbial threats. Ecological disruption, population growth, increased human mobility, poverty, wars and famine, migration, urbanisation, and global production and distribution channels of food have all served as facilitating variables or disease amplifiers that have eased the epidemiological transition of microbes into more pathogenic forms (Price-Smith 1998; see also Evans et al. 2004). Few microbes have caused more concern than the avian influenza virus, in particular the H5N1 strain, due to its rapid genetic mutations, ability to acquire genes from viruses infecting other species, and very high pathogenicity (WHO 2006). First identified in wild geese in China’s Guangdong province in 1996, the virus spread rapidly through the country’s large domestic duck population of 660 million, with pigs serving as a ‘mixing vessel’ from which the virus could cross a species barrier (WHO 2005).4 The first human infection was documented during a massive outbreak of H5N1 in Hong Kong in 1997 and traced to Guangdong, when the virus jumped directly from birds to humans, killing 6 and sickening 18 others (Garrett 2005a). Hong Kong’s rapid destruction of its entire poultry population of 1.5 million (within three days) probably averted a global pandemic (WHO 2006). Yet H5N1 itself was not eliminated. It merely retreated to southwest China and again in December 2003 in a super-virulent form—more pathogenic, resilient, adaptable, and capable of killing a broader range of species, including rodents, tigers, and humans. The outbreaks that followed in 2004 were the largest and deadliest on record: never before were so many countries ravaged by the avian influenza at the same time, and never with such a high fatality rate—both bird and human (WHO 2005). The lethal strain first infected flocks in Korea, Thailand, and Vietnam, and then travelled to Japan, Tibet, Russia, including Siberia, to reach Europe’s southeastern shores by October 2005. It had infected 109 people and killed 59 of them by May 2005, thus achieving a high morbidity rate (Garrett 2005a). By early 2005, with more than 140 million chickens killed by the virus or destroyed and customers shying away, outbreaks ravaged Asia’s poultry industry, with losses expected to
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have exceeded US$15 billion.5 Even in the absence of further human infection, the damage from another outbreak was set at US$50 billion to US$60 billion (WHO 2005, 54). Yet the worst was by no means over: the evolution of the virus suggested a deepening threat (5). The H5N1 strain had become endemic in southeast Asia, having found a permanent ecological niche in domestic poultry and asymptomatic ducks. Despite individual control measures, avian influenza continues to spread, creating further economic, ecological, and human devastation. Russian authorities warned that ‘the infection cannot be contained, and it is impossible to isolate’ and that the avian influenza ‘will have serious consequences for the environment, the economy, and primarily for human health’, making it imperative to legislate comprehensive anti-epidemic, sanitary, and veterinary measures (‘Bird Flu Confirmed in 45 Russian Settlements: Chief Veterinary Inspector’ 2005). Highly Pathogenic Avian Influenza Strikes Canada In Canada, a slightly higher number of dead chickens (8–16 per day) was reported in one barn in Fraser Valley, British Columbia, on 6 February 2004. Low-pathogenic avian influenza (LPAI) was confirmed on 16 February (Tweed et al. 2004). Although the flock was quickly quarantined and depopulated by the Canadian Food Inspection Agency (CFIA), within three weeks a highly pathogenic strain (H7N3) was detected in another flock on the same premise, killing 2000 birds in two days. With this started the largest outbreak of highly pathogenic avian influenza (HPAI) in Canada—the first since 1960 (Chicken Farmers of Canada 2004, 6). Despite the containment efforts, the virus continued to spread, infecting more than 50 commercial and backyard farms. More drastic measures, including the destruction of 17 million chickens, turkeys, and ducks, stopped the viral progress by 4 June. But it took another two months of disinfection for all the remaining restrictions to be lifted (5). Those six months of the HPAI scare had a significant negative impact on the province of British Columbia chicken industry in terms of farm sales, cleaning and disinfecting costs, increased bio-security, and industry coordination. As trade partners banned various poultry imports—from all of Canada—the total losses for the chicken industry were estimated at CA$100 million in the first year of recovery (Chicken Farmers of Canada 2004, 7). The Fraser Valley outbreaks also represented the first known case of human H7N3 infections.6 Lessons Relearned British Columbia’s frightening episode was not without precedent: SARS should have been an eye opener for the whole world. SARS had jumped to humans from infected animals that were sold and slaughtered in unsanitary and crowded markets in China’s Guangdong province, from where it travelled to five countries within 24 hours and across six continents in several months, causing 8000 infections worldwide, with a 10 percent mortality rate (Osterholm 2005). The crisis demonstrated that a lack of proper agricultural practices and sanitary standards in one corner of the
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world can imperil the livelihoods of people an ocean away, that infectious pathogens can encircle the globe in a matter of days in the age of international travel, and that the public’s fearful reaction can deliver the final blow to an already crippled economy. This should have underlined the urgent need to strengthen the global capacity for disease surveillance, increase reporting transparency, and improve regional cooperation (FAO and OIE 2005a). Public health authorities did try to increase the control of microbes in the aftermath of SARS. Yet it remains doubtful that the critical lessons that SARS should have taught have been internalised. Despite the critical need for a stronger global public health infrastructure, the international community continued to under-invest in an efficient and effective global system of outbreak surveillance and response (Evans et al. 2004). A virus is most lethal where the target population is already immuno-compromised by disease, malnutrition, and poor sanitation, or where the health infrastructure is unable to contain it. It is impossible to estimate the extra impact of avian influenza on cramped refugee camps, on famine-stricken areas, on sprawling slums lacking clean water and medical facilities, or on the 33.2 million people living with HIV/AIDS (Garrett 2005a; WHO 2005). So how can one prepare, in the context of inadequate global health care, for a pandemic far deadlier and far more difficult to control than SARS, one that would indiscriminately affect every sector of society (Osterholm 2005)?
Global Governance versus Microbial Globalisation Global collaboration is the only way to fight epidemics in the age of globalisation: a global disease requires a global health policy and global governance framework that involves a multiplicity of actors—including national governments, international agencies, private and corporate actors, and civil society (Aginam 2004). Avian influenza, by its nature, lies at the complex interface between farming practices, livestock trade, food safety, and public health security (FAO and OIE 2005a). This section therefore explores the overlapping layers of the global health architecture to underscore the need for participatory processes, multi-stakeholder consultations, cross-sectoral linkages, and local engagement in the transnational pandemic plans, starting with the UN.7 International Coordination of Preparedness Planning Although it was relatively localised and contained, the shock of the Asian tsunami in December 2004 exposed the poor shape of the UN’s inter-agency coordination. It also prompted critical review of the UN’s role in national preparedness plans in different countries—and a far more immediate response to avian influenza.8 The World Health Organization (WHO) is the default agency when it comes to health-related issues.9 But the complexity of avian influenza makes it necessary to engage other actors that are better placed to address the zoonotic or security side of
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health. Nothing less than an integrated international health network, comprising the WHO, the World Food Programme (WFP), the Food and Agriculture Organization (FAO), the United Nations Environment Programme (UNEP), the United Nations Development Programme (UNDP), national health institutions, and civil society representatives is needed. Since the control of emerging infectious diseases lies ‘beyond the responsibilities of any one organization’ (Bradford and Linn 2004, 4), defeating HPAI calls for an inter-sectoral, inter-institutional approach. The WHO has already been working alongside the FAO and the World Organisation for Animal Health (OIE) to create a ‘master coordination plan [that would] be prepared with a global vision defining the road map and time frames for the short-, medium- and long-term priority activities, to be endorsed and supported by individual countries ���������������������������� and regional organisations��’ (FAO and OIE 2005b). That was the first step toward elaborating a global strategy for the control of HPAI. However, the OIE—like all other agencies—is weakened by its exclusive reliance on the information supplied by its member states and their voluntary (and often problematic) compliance (Otte et al. 2004, 43). Global economic institutions also cannot remain on the sidelines. In cooperation with the WHO, the International Monetary Fund (IMF) and the World Bank should relax the strictures that have a negative impact on the health sector (Carin 2005). The World Trade Organization (WTO) should develop pro-health trade incentives and revise its Agreement on the Application of Sanitary and Phytosanitary Measures (SPS Agreement), which provides a framework for the protection of human, animal, and plant health and life; at the same time, it should prevent unjustified trade barriers from being erected (Otte et al. 2004, 44). The International Labour Organization (ILO), for its part, could sponsor a global health workforce summit to address the troubling migration of health practitioners from developing countries (Carin 2005). National Preparedness Plans: State Responsibilities in the Borderless World of Microbes However, for all their expertise, international agencies lack public accountability, and hence authority, to impose and enforce the far-reaching measures required in a pandemic. For better or worse, this responsibility rests with national governments (Bradford and Linn 2004). It is encouraging that most governments have taken steps, to varying degrees, to deal with avian influenza. Yet there is far more to be done, beginning with a detailed blueprint of how to get their citizens through one to three years of a pandemic (Osterholm 2005). Every country’s policy makers must develop a contingency plan at the domestic level for the worst-case scenario involving quarantines, weakened armed forces, dwindling hospital space, and vaccine scarcity—and engage all key components of the society (Garrett 2005a).10 The committed leadership of countries such as Canada, with direct experience of a pandemic and the resources to contain a new outbreak, is key in strengthening global health governance.
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Profit and Responsibility: The Place of the Private Sector in Disease Control Businesses and farmers have a significantly greater responsibility to monitor, inspect, and report outbreaks in a system where privatisation, deregulation, and decentralisation of animal health services have eroded the governments’ ability to control and regulate emerging infectious diseases (Otte et al. 2004; Osterholm 2005). It is debatable, however, whether voluntary codes of conduct can replace mandatory regulation in the context of a looming pandemic. The private sector’s attention to the bottom line has meant that the overall record, around the world, has not been encouraging. This has made it increasingly necessary to enlist the broad potential of civic responsibility—including that of consumers as civic actors—to lobby their governments and exert pressure on businesses to ensure compliance with the minimum standards of socially responsible corporate behaviour. Bolstering Defence from the Ground Up: The Role of Civil Society The nature of civil society players is varied—and varies by country—but engaging their local knowledge and global reach in avian influenza policy is crucial for reducing cross-sectoral losses. Who can best support, and often deliver, local health care? Respond to humanitarian crises? Identify farmers sidestepping regulation because of poverty or recalcitrance? Mobilise the public in non-coercive ways? Who enjoys public trust? Early engagement of civil society can provide legitimisation for difficult policy choices. Neither international agencies nor national governments can match the level of public trust in civil society organisations. Civil society can also play a unique role in awareness raising, in terms of both prevention and risk management (for example, by exposing the risk from poultry products). It can also help identify gaps in regulation, press for compliance, and advocate for change. But civil society’s responsibility goes beyond public advocacy to include key aspects of both implementation and delivery. Many developing countries depend on health-related NGOs to make up for their own institutional weakness and impaired public health delivery. Civil society is essential for the sustainability of technical assistance by ensuring that aid can actually be absorbed by national health authorities—and translated into real care (Kuchenbecker 2004). Civil society is also a source of expertise, analysis, and policy formulation, and makes a significant contribution to public policy debates. With their grassroots engagement and their function as a channel for communitybased knowledge, civil society organisations also often have a clearer picture of human and technical needs and capacities. This means that public or private partnerships with community groups can significantly increase returns on health and agricultural investment. Civil society actors also perform disease surveillance, which is a key component in the fight against pandemics. When the Chinese government refused to disclose the magnitude of the SARS outbreak, it was the WHO’s ability to tap the
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nongovernmental sources of epidemiological information that helped contain the epidemic (Fidler 2004b). Not surprisingly, the WHO has struggled for years to make ‘germ governance’ more inclusive—and effective—by relying on nongovernmental or civil society organisations to challenge the state’s monopoly on public health. Governments alone cannot handle global microbial threats (Fidler 2004b). However, donor governments and international agencies often assume, wrongly, that developing countries have a civil society network capable of participating in policy formulation, monitoring, and implementation (Kuchenbecker 2004). Yet the nongovernmental sector in many recipient countries is weak or subordinated and it cannot make up for the weaknesses in state capacity. This means that health investment must be coupled with strategies to develop a local civil society capable of administering that aid. This great risk of avian influenza and similar global challenges represent an opportunity to build on the work of the high-level panel on UN and civil society, chaired by former Brazilian president Fernando Henrique Cardoso. This initiative should begin by looking at the issue of trust in civil, corporate, and public actors and capacity building. It should explore the role of the private sector in seeding civil society organisations in countries where they would not otherwise flourish (such as through the International Ministerial Conference on Avian and Pandemic Influenza that was held in Bamako in 2006 and the subsequent technical meeting held in New Delhi in 2007). At the same time, civil society actors, given their non-elected status, also need to be more self-critical and accountable. The response to the 2004 Asian tsunami brought into sharp relief the lack of coordination and the mandate creep of multilateral agencies. It showed equally that both the best and the worst of civil society organisations can tarnish the credibility of all. Ultimately, it eroded their ability to work effectively with full trust. Adding the Building Blocs: Policy Harmonisation and Institutionalisation As a basic step, it is necessary to address right at the start a series of institutional deficits, jurisdictional overlaps, and procedural gaps. First, there is a regulatory and policy vacuum that spans human and animal health and agriculture. It must be replaced by an institutionalised, law-based (and thus enforceable) regulatory framework that governs bio-security, vaccination, the administration of antibiotics, animal movement, border control, the culling and disposal of carcasses, farmer compensation, the restructuring of the poultry industry, and so on. Harmonisation must occur within government bureaucracies as well as across government agencies on the basis of the best practices available. Ultimately, the institutional deficit between public and animal health services needs to be resolved. It is no coincidence that the countries most affected by HPAI are the ones with deficient veterinary services, farm bio-security measures, and animal disease information systems (FAO and OEI 2005a). In other cases, there is no clear division of labour between the principal international agencies, which costs millions of dollars every year in duplication. Civil society should be empowered to work
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in these inter-institutional spaces as a watchdog providing oversight, facilitating coordination and strategic linkages, ensuring accountability, and offering a critical analysis of the nature of institution building. The same holds true of institution building at the national level. Scrapping institutions every time disaster strikes and starting from scratch is impractical. This costly habit wastes human resources, erases institutional memory, and cheats public expectations. Instead, existing institutions should be equipped to deal with any threat, be it Y2K, September 11, flooding, a new infectious disease, or a biological attack.
The Global Agenda Poverty and Ill Health: Breaking the Cycle There would be far less cause for concern if medical capacity around the world were adequate. Yet the capacity to respond to global threats is severely unbalanced, as the state of global public health has reached crisis proportions (Bradford and Linn 2004). Countries are nowhere near meeting the MDGs on health by 2015. Most world governments lack sufficient funds to act. No national health infrastructure today would be able to handle, at once, the combined burden of a pandemic, social disruption, and ensuing public unrest, but the international community would still look to the United States, Canada, Japan, and the European Union for answers, vaccines, cures, money, and hope (Garrett 2005a). So would their own citizens. There is no easy solution to this crisis. But certain structural changes could help mitigate its causes—and lessen the impact of avian influenza. Because it tends to afflict those countries that lack the capacity to contain it, defeating the virus requires breaking the ‘deadly partnership of poverty and ill health’ (Aginam 2004).11 If a mere US$34 per person per year were allotted to health care, education, and sanitation, 8 million lives could be saved every year by 2010—with direct and indirect economic benefits totalling US$360 billion annually (Commission on Macroeconomics and Health 2001). But public health systems in rich countries have also come under strain. The anthrax scare in the U.S. in 2001 underscored the inability of federal and local health agencies to respond effectively either to bioterrorism or epidemic threats (Garrett 2005a). Because of budget cuts in recent years, one of the greatest weaknesses that each country must address is the inability of its hospitals to deal with a sudden surge of patients. The historically unprecedented HPAI outbreaks in southeast Asia’s poultry industry in 2004 also revealed a direct correlation between national intervention capacity and industrial practices on the one hand and viral spread on the other. Japan and Korea fared best, because the disease remained limited to commercial farms, and was rapidly detected and hence effectively contained. Control measures were less successful in Thailand and Vietnam, where nearly every household kept a flock of intermingling chickens and ducks. Cambodia and Laos were even worse off,
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because they could not raise sufficient funds to contain the spread. Indonesian health authorities had to contain a huge outbreak of the dengue fever (which had infected 58 000 people and left 650 dead), sparing few resources to handle an animal disease (WHO 2005). The big success stories—the countries that managed to control and eradicate the HPAI infection on their chicken farms—were a handful of wealthy states in Europe and North America (FAO and OIE 2005a). This was not merely a matter of having the resources for a rapid response, but also of having the right preconditions—an organised and sanitary commercial poultry industry, which, in turn, is a function of domestic resources and health standards. Having an integrated private sector with robust state support helps absorb the potential financial loses of preparedness. With other social priorities and diseases competing for scarce resources, preparing for another emergency or containing a ‘mere’ animal infection may seem like a luxury. Yet the world cannot afford to ignore HPAI. Preparedness planning, by its very nature, cannot wait until the onset of the catastrophe: it calls for preventive measures, from early warning to vaccine development (WHO 2005). Making Money Work: Capacity Building and Technical Assistance Financing is critical to the success of the global response. But beyond the price tag lies the far greater challenge of making money work (Soni 2004). Sustainable policies require investment in technical assistance and absorptive capacity, tackling the politically tricky question of health worker brain drain and providing leadership on trade (including drug access). Civil society must be engaged in all these activities, both as a watchdog and a trusted implementing partner. First, the framework for managing avian influenza must not turn out to be a shortterm fix like too many other health investments.12 Civil society organisations must be empowered to monitor the states’ delivery on their promises and to ensure that funds are not funnelled to other activities. Second, a good portion of the investment ought to be devoted to local capacity building. The situation with HIV/AIDS, tuberculosis (TB), and malaria in developing countries carries important lessons for efforts to manage avian influenza; even where donors have marshalled sufficient resources and will, they have encountered the challenge of implementing accelerated, large-scale programmes in resource-poor settings. Inadequate capacity in recipient countries has been a principal limiting factor for stamping out infectious diseases.13 Any healthrelated financial aid package must incorporate the technical assistance needed to help countries run their programmes independently, develop the local public health infrastructures capable of absorbing the large influx of aid, and facilitate the training of local personnel. This also raises the issue of transparency of financial aid, in which the independent voice of civil society and its freedom of action become the critical guarantee that multilateral assistance would reach its target population. In essence, civil society organisations provide ‘servant leadership’, acting at once as watchdogs, advocates, and partners in knowledge transfer.
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Preparing for the Long Haul: Taking an Integrated Approach to Human and Animal Health Animal Health: Vanguard Defence With potentially catastrophic human losses, it is easy to forget that avian influenza is principally an animal disease and its effective prevention lies in the domain of animal health. Given that the causative viral strains in all three major influenza pandemics in the 20th century originated from animals and the staggering economic damages from livestock-disease outbreaks, a ‘global system of animal health protection is a global public good’ (Otte et al. 2004, 15; see also FAO and OIE 2005a). Most countries cannot handle alone the costs of prevention and control of transboundary animal diseases. This implies a need for collectively agreed, funded, and managed responses (Otte et al. 2004). In effect, humanity’s first line of defence against avian influenza rests with responsible farming practices—which is a global responsibility. Containment through Agricultural Reform The WHO has concluded that fundamental changes in agricultural practices may well be the only viable long-term solution to stop avian influenza (WHO 2005). Outbreaks in rural areas in southeast Asia are the main source of increased human exposure, where live poultry markets are considered the ‘missing link in the epidemiology of influenza’ and asymptomatic domestic ducks are a ‘reservoir of disease’ (FAO, OIE, and WHO 2005,1 6; FAO and OIE 2005a, 17).14 Although costly and controversial, the necessary measures must address the high-risk practices related to poultry farming and marketing, including live bird markets and farm hygiene (FAO and OIE 2005a). Regulating (and, ultimately, reducing) the prevalence of duck and chicken farming is the most effective strategy to deny the virus access to its human hosts. Farming reform must simultaneously provide an alternative source of protein, income, and employment through rural development, education, and financial aid. This underlines the role of national governments in monitoring, educating, and enforcing—and of the international community, including civil society organisations—in underwriting these efforts. Aquatic viruses are more likely to spread to domestic animals—and then humans—in China than anywhere else in the world (Garrett 2005a). One cause is the country’s severe ecological disruption. Another is its particular agricultural system (where raising chickens, ducks, and pigs together in tiny backyards has greatly increased the risk of infection), as is the interface of economic development and poor sanitation. China’s rising gross domestic product (GDP) has increased the taste of its 1.3 billion people for meat; as such, its growing chicken industry (with more than 13 billion birds) is starting to rival U.S. farms in scale, but it lags behind in hygienic standards (Garrett 2005a). Beijing’s partner governments need to secure its cooperation and support its domestic awareness-raising programmes, but transnational civil society networks equally need to aid their Chinese counterparts in creating grassroots organisations capable of launching local plans to sensitise China’s large farming community to the risks of avian influenza.
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Beyond such production practices, other factors are amplifying avian influenza’s deadly potential. These include unsustainable consumption patterns and dietary demands, which make it necessary to address the problems of agricultural antibiotics, antimicrobial resistance, vaccine scarcity, intellectual property, and international trade regulations. Consumption Patterns, Agricultural Antibiotics, and Antimicrobial Resistance Most animal and plant antibiotics that are added daily to livestock feed, aquaculture waters, and seed stocks are used to promote growth, and the industry is indisposed to give them up: bigger animals, fish, and fruit bring bigger profits. Yet many compounds, being chemically identical to medicinal antibiotics, cause microbial resistance to human antibiotics (Garrett 2005a). By limiting the efficacy of lifesaving health technologies and making the public more vulnerable to microbial mortality, the routine use of growth promoters for non-medicinal purposes poses a direct threat to global health (Garrett 2005a; Fidler 2004a). Since antimicrobial resistance is as much about economics as it is about health, government regulation (and even proscriptions in some cases) of antimicrobial drugs in domestic agriculture may be necessary to end their misuse. This is a policy on which the EU has already taken the lead. In the interest of public health, other countries should consider following the European example (even ahead of an international agreement) and issuing similar guidelines on high-risk meat imports.15 In Defence of the Precautionary Principle: Public Health and International Trade Although justified from the public health perspective, such actions remain open to a legal challenge under international trade rules (Fidler 2004b). Trade policy profoundly affects health; yet there have been few incentives to adopt health-minded policies in trade negotiations. Trade rounds have more often tended to limit access to life-saving drugs via agreements on intellectual property rights (Fidler 2004b) or to abolish the right of governments to resort to the precautionary principle in the interest of public health. There is some scope for progress, however, as the global response to the AIDS epidemic illustrates. A confluence of civil society pressure on western governments and producers in recent years helped bring down the price of the AIDS cocktail from US$15 000 to US$150 per person per year (Keusch et al. 2006). It also paved the way for the WTO’s Declaration on the TRIPS Agreement and Public Health in 2001, which gave this growing consensus a basis in law (Soni 2004; Fidler 2004b). The transatlantic trade war that erupted in 1999 over the EU ban on hormonetreated beef offers a cautionary tale. The Europeans blocked beef imports for public safety reasons, citing the precautionary principle, which requires authorities to proceed cautiously to avoid irreversible damage in situations where there is insufficient scientific evidence but the possible damage could be significant. The American and Canadian governments denounced this action as a non-tariff trade barrier, took the EU to the WTO’s dispute panel, and won—three times. Preventing a similar dispute from erupting in the future would require Ottawa and Washington
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to rethink the relevant provisions under the North American Free Trade Agreement (NAFTA) and the WTO. Consumer groups have a key duty in this context to elevate the public’s consciousness about health and to promote responsible consumer behaviour. The price of reining in the spread of avian influenza or future threats may yield smaller tomatoes and fewer chicken eggs, which may perhaps be a reasonable cost to the consumers in wealthy countries. The establishment of a joint WHO/FAO commission could reduce the incidence of trade disputes, which are damaging both to the economy and health.16 In the meantime, individual country guidelines on (international) standards on antibiotics and vaccination in agriculture must be implemented in close consultation with the domestic farming community—which not only is responsible for operationalising new rules but which will also experience their effects on its bottom line. It is one thing to get farmers and agronomists in Canada to agree to abide by these rules and quite another in southeast Asia, say, where the HPAI virus has become endemic and where the smallholder poultry industry accounts for some 70 percent of the total chicken production and involves some 200 million poor farmers—with little or no access to preventive treatment, disease information, and veterinary services (FAO and OIE 2005a). This makes civil society’s advocacy and monitoring efforts critical for the success of any national action plan. Too Little, Too Late: Global Vaccine Scarcity The trouble with the H5N1 virus, unlike with the more common varieties of avian influenza, is that the vulnerable age group cannot be predicted—which means that any individual who comes into contact with the virus is at risk, although in Turkey in January 2006 there was significantly higher mortality among those younger than 15. For the U.S. alone, this translates into a need for at least 300 million doses of vaccine, which is the amount the whole world together produces in a year (Garrett 2005a). Furthermore, vaccines are produced commercially in just nine countries—Australia, Canada, France, Germany, Italy, Japan, the Netherlands, the United Kingdom, and the United States—home to barely 12 percent of the world’s population, while companies still lack financial incentives to invest in a product that may never reach the market and thus never turn a profit (Garrett 2005a; Osterholm 2005).17 In 2003, the entire world market for vaccines, from polio to measles to influenza, made up less than 2 percent of the global pharmaceutical trade (Garrett 2005a). Indeed, if the entire U.S. vaccine production system was devoted to making a vaccine to combat an avian influenza pandemic, it could inoculate barely 5 percent of its population (Butler 2005). The U.S. government was stockpiling the vaccine; but if American vaccine production were to falter, as it did in the 2004 influenza season, it could not rely on Canada and Germany to bail it out as in 2005, because, in a ‘global scramble for vaccine’, governments might block foreign access to their supplies, ban exports, nationalise the domestic production facilities, or refuse to share their vaccine (just as Washington did in 1976, in anticipation of the H1N1 swine influenza) (Garrett 2005a; Osterholm 2005).18
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Ultimately, global scarcity of the influenza vaccine is only marginally relevant to most of the world’s 6 billion people, who would go unvaccinated, even though between 30 percent and 50 percent would get infected in a pandemic (Garrett 2005a).19 Yet national pandemic influenza preparedness, by its nature, is an international issue: in a world lacking equitable access to the cure, even the vaccinated would face devastation if the global economy were to stop in its tracks (Osterholm 2005). Instead of hoarding the vaccine, the West ought to release it to the most vulnerable, because the regions the first to be hit would also be the first line of defence. Thus the whole world must rely on the wealthy countries enlightened self-interest to develop a vaccine against this pandemic virus—a complex and costly undertaking (WHO 2005)—and to share it first with the poor. Not only is stockpiling ineffective from the standpoint of global containment, but it is not even feasible: a true pandemic vaccine (which must match the actual strain of the virus) must wait for its onset, while virtually every other piece of medical equipment would also be in short supply.20 In brief, vaccine development must not detract from the need to invest in broader preparedness plans (see Butler 2005).
Threat Perceptions: Reframing Public Health and Infectious Disease Control Up to this point, discussion has centred on the significant structural obstacles to implementing a global action plan in the context of limited state capacity or traditional farming practices. But the problem of ideational discrepancies or divergent priorities must also not be underestimated. Different stakeholders approach the issue of human influenza from different angles, which need to be reconciled in order to develop a plan that is truly global in nature and executable in practice. In this section, the dominant perspectives on global public health are considered—namely, developmental, human rights, security, and environmental—focussing on what each has to contribute to our understanding of the impending challenges. The Human Development Paradigm: Locating Avian Influenza on the Development Agenda The growing attention to avian influenza outbreaks in southeast Asia could help galvanise action. But it could also crowd out the broader public health strategies needed for long-term sustainability. Among the key questions facing national and international public health authorities is the issue of how to launch a global influenza action plan that would simultaneously strengthen public health infrastructures in poor countries. Global health problems must be addressed within a multi-sectoral approach consistent with the MDGs, while any health plan ought to be set in motion with complementary global action plans in education, environment, water, and sanitation.21 A human development paradigm brings together these interconnected imperatives in a single policy framework, making it evident that broad systemic and
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institutional changes are required to lead humanity out from the shadow of another influenza pandemic. Developing countries might still view it as hypocritical or self-serving that the new global health agenda has put a premium on those diseases that pose a threat to the wealthy (such as Ebola, SARS, and now avian influenza), while discounting the non-acute or non-epidemic infections (such as cholera or typhoid) that remain largely confined to the global South. But an influenza pandemic is different from other emerging infectious diseases given its frightening potential to overwhelm the entire international system—a risk never associated with either HIV or malaria, despite their destructive impact on individual countries (Osterholm 2005). It is necessary to balance the narrow focus on containing avian influenza with a broader public health strategy to solve the healthcare crisis in general. However, these are two interconnected imperatives: a preparedness plan for avian influenza would automatically feed into the parallel efforts to strengthen the public health system, while investment in national healthcare infrastructures and development is an investment in the global future. The Human Rights Perspective: Fundamental Liberties, Social Cohesion, and Distributive Justice Human rights considerations, if embedded in national public health legislation and supported by monitored international agreements, can help communities maintain the delicate balance between public health and individual rights in the face of quarantines, isolation, civil liberties, triage, and restrictions on work, trade, immigration, assembly, and travel. The refusal of one healthcare worker to comply with voluntary isolation measures was responsible for infecting dozens with SARS in a Toronto religious community. Draconian measures may be unavoidable in some cases, but civil society must be able to ascertain that such measures are transparent, lawful, and warranted. By the same token, civil society organisations must also ensure that their members respect the voluntary or mandatory codes in the interest of public safety, be they local trade unions, faith groups, or community associations. Civil society’s higher rate of popular trust imposes on it a special obligation to take community leadership on these issues. There is also a danger that a pandemic could create ethno-racial fissures rather than unity and inter-communal tolerance if, for instance, a disease erupts predominantly in a single ethnic group. A human rights approach could help a multicultural society such as Canada avert this outcome to dispel the perception of racism-minded marginalisation or ghetto-isation of ethnic neighbourhoods especially hard hit by avian influenza. The same human rights perspective should guide policy makers in managing the legal and socioeconomic consequences of the pandemic—an issue altogether separate from managing the outbreak. The need for distributive justice and fairness, so frequently emphasised by civil society groups, sits squarely within this framework.
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Public Health Security: The Risks and Benefits of Securitising Health With a growing concern about bioterrorism since September 11, 2001, security has become the lens through which policy makers in the West increasingly view public health issues.22 Securitising health is by no means uncontroversial, but a pandemic influenza would be a public security threat as much as it would be a public health one. The security dimension of infectious disease could be severe: from the direct effect of human incapacitation to domestic instability (SARS caused the worst crisis for China’s leadership since Tiananmen Square) and cross-border tensions (Garrett 2005a; Osterholm 2005; Price-Smith 2008). Security will especially be at stake where avian influenza combines with overpopulation, environmental degradation, and resource scarcity to induce mass exoduses over state borders from poor to wealthy countries (Price-Smith 2008). States will be tempted to close their borders or impose quarantines in an attempt to protect their own citizens even though, short of disrupting trade, travel, and productivity, these measures rarely work (Garrett 2005a). Disease pathogens do not respect the territorial boundaries of sovereign states, thus rendering isolationism a futile and counterproductive public health strategy in an era of global epidemics (Aginam 2004). Many critics fear that this approach may divert essential resources and attention from the more critical diseases plaguing the world’s poor (‘Meeting Report’ 2004). But these two dimensions of international disease control are mutually reinforcing: investing in the global health security infrastructure through capacity building would advance the same goals as a health-based framework focussed on primary health care, just as bolstering emergency preparedness to respond to infectious diseases would equip individuals for any eventuality—even that of bioterrorism (Fidler 2004b; Heymann and Drager 2004). Environmental Security: Ecological Disequilibrium and Human Health Global ecological disequilibrium is directly tied to the threat of emerging infectious diseases. The virulence of existing pathogens has increased, thanks to the rapid destruction of the biosphere, soaring population densities and mass migrations, and ozone depletion, not to mention ‘green’ agricultural revolutions that turn rainforests into ranches and farms into mass production factories, and introduce antibiotics that seep into livestock feeds. These developments have not only increased the virulence of existing pathogens, but have also released entirely new infectious vectors (PriceSmith 1998, 2008; Otte et al. 2004). Most critically, global climate change is expanding the breeding ground for viruses at the same time as it is weakening many countries’ ability to cope with natural disasters, food and water shortages, and public health threats. Evidence of intensifying climate change is thus particularly troubling in terms of humanity’s ability to prevent and fend off or adapt to a global epidemic. Protecting the natural environment can no longer be postponed. And it must be done with the full force of the law. But mainstreaming environmental considerations
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into public health planning across agencies demands a more inclusive framework discussed in the last section (Otte et al. 2004).23
Conclusions and Recommendations Back to Basics: Human Security as the Answer? One thing is clear: avian influenza and similar global epidemics cannot be defeated as long as its multiple causes are not eliminated. First, we need a genuine commitment to human development, which implies tackling the structural and institutional sources of deprivation, disempowerment, and inequitable access to health services (‘Meeting Report’ 2004). Second, we need a dependable human rights system to protect the feeble, the poor, and the marginalised during any crisis of vast proportions, just as we require a humanised public security framework to awaken policy makers to the security threats presented by ill health and structural violence. Third, we need to take environmental responsibilities seriously, while the interaction with animals and the handling of animal production, processing, and marketing for food all need to change (FAO, OIE, and WHO 2005). These are complex long-term agendas, and the time and resources of international policy makers are more likely to be focussed on more immediate issues. Yet these processes need to unfold in tandem, because trade, aid, financing, drug production, hygiene, dietary patterns, animals, birds, and humans all feed into the H5N1 mix. This situation leaves two timeframes and multiple, seemingly disjointed concerns. Poor countries worry about diverting attention from development. Different government agencies in the wealthy countries prioritise either public health or security. NGOs tend to stress the potential human rights implications. The private sector calculates the economic impact of avian influenza. Yet containing and, ultimately, eliminating the virus depend critically on the ability to obtain the maximum support of all societal actors. Taking the perspective of human security—which places health, wealth, security, prosperity, and sustainable development within one inclusive framework—is one way to bring these divergent elements together. Unlike more traditional approaches to security, human security addresses the more mundane questions of daily survival: hunger, disease, poverty, environmental degradation, and conflict. Most importantly, it is results-oriented: as noted in the 1994 Human Development Report, ‘in the final analysis, human security is a child who did not die, a disease that did not spread, a job that was not cut, an ethnic tension that did not explode into violence, a dissident who was not silenced … Human security … is a concern with human life and dignity’ (UNDP 1994, 22). By providing a common language among stakeholders—veterinarians, environmentalists, chief executive officers, civil servants, farmers, diplomats, military chiefs, and health practitioners— human security might help mobilise support and establish a broad consensus on the policies and strategies needed to wean societies away from high-risk practices.
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On the other hand, there is also a need to take risks, including the risk involved in working together to seek solutions from policy to implementation. This proposal is not revolutionary, least of all in Canada: several lessons can be taken away from the so-called ‘Track II’ governance model that has served so well in the past: first, partnership delivers—if governments and NGOs can overcome their mutual apprehensions about teamwork (see Cameron 1998). Second, even small powers, united in a coalition of the likeminded and acting jointly with global civil society, can mobilise to serve the marginalised. Third, traditional mechanisms, which work as long as states are willing to move as fast as the slowest in the pack, can—and should—be bypassed when they stand in the way of urgent action (Cameron 1998). ‘Ad hoc multilateralism’ or coalitions of the likeminded may be preferable in crisis situations. Nevertheless, Canada’s ‘new multilateralism’—an attempt to engage both state and non-state actors on key global issues in a variety of traditional and innovative forums—should fit within the UN matrix and not act as a substitute for it; it should move the consensus forward, without detracting from the inclusiveness and universality of the UN’s framework. Ottawa’s health ministerial in October 2005 was a real-life example of such a response. The potential emergency presented by avian influenza warrants the Track II human security model every bit as much as landmines did. It also justifies governments reaching out to their civil society partners for help, expertise, guidance, legitimisation, delivery capabilities, and support. Civil society organisations, for their part, are obliged to provide capacity, directions, and solutions, as well as to raise red flags when necessary, including on their own culpabilities. And if the avian influenza never comes, will this all have been a flap over nothing? Clearly not: today no one is adequately prepared to face any virulent, bioterrorist, or cataclysmic enemy. The approach put forward in this chapter is an integrated, law-based, human security strategy, designed not only to bolster defences against this specific fearsome virus but also to build system resilience—to build true emergency preparedness. Forging partnerships and increasing fairness, equity, and transparency in general, beyond the immediate time horizons, will leave individuals better equipped to repel other threats. The global perspective will also encourage adequate redistribution of resources (envisaged in the MDGs) by channelling scarce supplies first to those in greatest need. This is a good investment, whatever the future brings. It will never be possible to create a disease-free world (Garrett 2005b). But if the big epidemic comes, individuals will be more likely to be ready. Civil Society Action Civil society has the opportunity to collectively identify and address concerns about avian influenza. Civil society must raise the same issues: cooperation (of civil society organisations), vaccine development and access, surveillance and capacity. There are other questions on technical capacity, apart from advocacy or aid delivery. Answers to the challenging questions of capacity, both human and technical, will need to move from national or bilateral to multilateral. A study at the Brazilian Institute of
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Social and Economic Analysis has suggested that civil society is also changing, and a separation between advocacy and delivery of aid is emerging—and the ‘freelancing’ unaffiliated advocate. This process does not focus on the larger question of what (or who) is civil society, but, after the Cardoso report, this question is worthy of its own focus. It is hoped that this chapter will expose opportunities and gaps for the grassroots and international civil society organisations that are already working at containing the effects or spread of avian influenza in creative partnerships with governments, citizens, and the private sector.
Notes 1 The opinions expressed here are those of the authors and not of the United Nations Association in Canada. 2 Indeed, the discussions and recommendations in an earlier draft of this chapter had a direct influence on the work done by the special appointee of the United Nations secretary general and on the International Federation of Red Cross, among other organisations. 3 One factor divides society from total disaster: the virus has yet to develop efficient human-to-human transmission (WHO 2005; Food and Agriculture Organization [FAO], World Organisation for Animal Health [OIE], and WHO 2005). 4 In an infected pig cell, avian influenza mutates from an avian to a mammalian virus, which can lead to a human epidemic. The H5N1 virus had moved to pigs by April 2005 (FAO and OIE 2005a; WHO 2006; Garrett 2005a). 5 The poultry farm losses in 2004 cost Thailand US$1.2 billion, Vietnam US$0.3 billion, and all of Asia as much as US$15 billion (WHO 2005, 54). 6 Avian influenza was suspected in 57 persons, confirmed in two, and killed none (Tweed et al. 2004). The results would have been more severe had it been the H5N1 strain. 7 On the need for multi-stakeholder collaboration, see FAO and OIE (2005a), Colin Bradford (2005), and M. Otte, R. Nugent, and A. McLeod (2004). 8 For example, the UN secretary general (2005) appointed a senior system coordinator for avian and human influenza in 2005. 9 The WHO took the unprecedented step in 2003 of independently issuing global alerts and travel advisories about SARS-affected countries without their authorisation, causing serious economic damage. Although some complained, including Canada, none publicly challenged the WHO’s authority during the outbreak (see Chapter 4). In May 2003, its members formally empowered it to take such actions in the future (see Fidler 2004b). 10 In January 2005, Vietnam, for instance, established an inter-agency working group consisting of technical experts and senior staff members from ministries of health, agriculture, and rural development all in close consultation with the international agencies (WHO 2005, 55; Osterholm 2005). 11 On the issue of mutual interest, see David Heymann and Nick Drager (2004). 12 Despite a rhetorical commitment to disease financing, aid not only continues to fall short of the WHO targets, but has also been cut in recent times (Soni 2004; Garrett 2005b). 13 Some 50 percent of the projects submitted to the Global Fund to Fight AIDS, Tuberculosis, and Malaria for financing are never approved due to technical imperfections, especially a lack of absorptive capacity (Kuchenbecker 2004). The Global Fund took back its money earmarked for Ukraine for that reason. According to Ricardo Kuchenbecker
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(2004), bilateral initiatives, such as the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), might offer an ‘advantage over the Global Fund, which simply making grants’. 14 Some 20 percent of the chickens sold in Hong Kong’s live poultry markets were infected with the H5N1 virus and later identified as the source of infection in its chicken farms in 1997; H5N1 was also discovered in the geese sold in the live poultry markets in Vietnam three years before the chicken farms outbreaks in 2004 (FAO, OIE, and WHO 2005). Studies in Vietnam have confirmed that some 20 percent of seemingly healthy ducks are constantly shedding the HPAI virus. Yet vaccination is not feasible because ducks react differently to the vaccine from chickens, and even continue to excrete the virus in increased quantities (FAO, OIE, and WHO 2005; WHO 2005). 15 For example, in Canada, as a result of bovine spongiform encephalopathy (BSE), the CFIA (2008) enhanced regulations to control ‘specified risk material’ in the animal feed chain (i.e., to prevent bovine remains from being fed to other farm animals). The agency ought to review the animal feed restrictions in order to ensure that risk material would also encompass parts from dead chickens and should consider banning the imports of meat that may have been fed in such a way. 16 Such a commission could be tasked with reviewing the use of all growth promoters and identifying the ones that play a role in increased drug resistance (Garrett 2005a). It could also develop a global action plan for antibiotic resistance with country-level monitoring and reporting (Fidler 2004b), as well as enforcing standards that, caused by short-term need, might also produce long-term equity. 17 It might be worth considering a 1976 piece of U.S. legislation that assigned corporate liability to the federal government in order to encourage the quick development of the swine influenza vaccine; that pandemic never happened, and Congress has not passed a similar law (Garrett 2005a). 18 The WHO convened a meeting in November 2004 to map out the respective responsibilities of all the key stakeholders—major influenza vaccine manufacturers, regulatory authorities, governments, and the WHO itself—to ensure a sufficient supply of the vaccine. It determined that the predicted shortfall could only be overcome through collaboration in the form of public funding, research, and partnerships. The pharmaceutical industry made some headway in research and development following the initial H5N1 alert in January 2004, but more remains to be done (WHO 2005). 19 The real impact of vaccines remains unclear. Despite the rapid vaccine development in 1957 and 1968, limited production capacity meant it arrived too late to be effective (WHO 2005). 20 For example, two U.S.-based companies produce most of the world’s masks from multiple component parts imported from various countries. If travel and transport were restricted in a pandemic, neither would be able to meet a jump in demand—in fact, masks may not be produced at all (Osterholm 2005). 21 Of the eight MDGs, three are health goals and other five are crucial to health (see Bradford Jr. 2005). 22 For example, the ministers of health of Canada, France, Germany, Japan, Italy, United States, United Kingdom, Mexico, and the European Commission created the Global Health Security Initiative, initially to deal with bioterrorism in 2001. 23 Mainstreaming environmental considerations would also help inform the decisions of all those governments that ban free-range farming (in favour of less humane indoor facilities) and order the slaughter of millions of wild waterfowl or culling of domestic birds.
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References Aginam, Obijifor (2004). ‘Between Isolationism and Mutual Vulnerability: A South–North Perspective on Global Governance of Epidemics in an Age of Globalization.’ Temple Law Review, vol. 77, pp. 297–312. ‘Bird Flu Confirmed in 45 Russian Settlements: Chief Veterinary Inspector.’ (2005). Ria Novosti, 6 September. Bradford Jr., Colin I. and Johannes F. Linn (2004). ‘Global Economic Governance at a Crossroads: Replacing the G7 with the G20.’ Brookings Institution Policy Brief 131. <www.brookings.edu/~/media/Files/rc/papers/2004/04globaleconomics_colin%20i%20 %20bradford%20%20jr/pb131.pdf> (September 2008). Bradford Jr., Colin I. (2005). Global Health and Global Governance: Prioritizing Health within the Framework of the Millennium Development Goals. Brookings Institution, Washington DC. <www.brookings.edu/papers/2005/0114development_bradford.aspx> (September 2008). Butler, Declan (2005). ‘Bird Flu Vaccine Not Up to Scratch.’ Nature News, 10 August. <www. nature.com/news/2005/050810/full/news050808-9.html> (September 2008). Cameron, Maxwell A. (1998). ‘The Landmine Ban: Globalization of Civil Society?’ Review, vol. 2, no. 1. <www.nsi-ins.ca/english/publications/review/v2n1/05.asp> (September 2008). Canadian Food Inspection Agency (2008). ‘Enhanced Animal Health Protection from BSE.’ Fact sheet. Ottawa. <www.inspection.gc.ca/english/anima/heasan/disemala/bseesb/enhren/ enhrene.shtml> (September 2008). Carin, Barry (2005). ‘The L20 Rationale and Conjectures on Its Values Added.’ Paper prepared for the India-Canada Policy Dialogue, New Delhi, 12–13 April. Asia Pacific Foundation of Canada and Centre for Policy Research. Chicken Farmers of Canada (2004). Annual Report 2004: Standing Together. Ottawa. <www.chicken.ca/app/DocRepository/1/Annual_Report/2004_English_AR.pdf> (September 2008). Commission on Macroeconomics and Health (2001). Macroeconomics and Health: Investing in Health for Economic Development. World Health Organization, Geneva. <www.cid. harvard.edu/archive/cmh/cmhreport.pdf> (September 2008). Evans, Timothy, Nick Drager, Ariel Pablos-Mendez, et al. (2004). ‘L20 and Global Public Health.’ Commissioned briefing notes prepared for the conference on ‘HIV/AIDS and Other Infectious Diseases’, Costa Rica, 12–13 November. Centre for International Governance Innovation, Waterloo. <www.cigionline.org : Conference Papers and Reports : Leaders’ 20 (L20) Project : Infectious Diseases and Global Health : Backgrounder> (September 2008). Fidler, David P. (2004a). ‘L20 Communiqué on Global Health.’ Paper prepared for the conference on ‘HIV/AIDS and Other Infectious Diseases’, Costa Rica, 12–13 November. Centre for International Governance Innovation, Waterloo. <www.cigionline.org : Conference Papers and Reports : Leaders’ 20 (L20) Project : Infectious Diseases and Global Health> (September 2008). Fidler, David P. (2004b). ‘Germs, Governance, and Global Public Health in the Wake of SARS.’ Journal of Clinical Investigation, vol. 113, no. 6, pp. 799–804. Food and Agriculture Organization and World Organisation for Animal Health (2005a). A Global Strategy for the Progressive Congrol of Highly Pathogenic Avian Influenza (HPAI). <www.fao.org/ag/againfo/resources/documents/empres/AI_globalstrategy.pdf> (September 2008).
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Food and Agriculture Organization and World Organisation for Animal Health (2005b). ‘Recommendation No. 1: The Ho Chi Minh City Declaration on Investments.’ Second FAO/OIE Regional Meeting on Avian Influenza Control in Asia, Ho Chi Minh City, 23–25 February. <www.oie.int/eng/avian_influenza/HPAI HCMC Recommendations_ March 05.pdf> (September 2008). Food and Agriculture Organization, World Organisation for Animal Health, and World Health Organization (2005). FAO/OIE/WHO Consultation on Avian Influenza and Human Health: Risk Reduction Measures in Producing, Marketing, and Living with Animals in Asia. Kuala Lumpur, 4–6 July. <www.wpro.who.int/NR/rdonlyres/38A980D7-8577-400A8024-7D27F34309D1/0/FAO_OIE_WHO_Consultation.pdf> (September 2008). Garrett, Laurie (2005a). ‘The Next Pandemic?’ Foreign Affairs, vol. 84, no. 4, pp. 3–13. <www.foreignaffairs.org/20050701faessay84401/laurie-garrett/the-next-pandemic.html> (September 2008). Garrett, Laurie (2005b). ‘Leaders Summit on Global Infectious Disease: Toward an L20?’ Paper prepared for a conference on ‘L20 and Preventing Pandemics‘, 15 May, Geneva. <www.cigionline.org : Conference Papers and Reports : Leaders’ 20 (L20) Project : Pandemics>. Heymann, David L. and Nick Drager (2004). ‘Emerging and Epidemic-Prone Infectious Diseases: Threats to Public Health Security.’ Paper prepared for the conference on ‘HIV/ AIDS and Other Infectious Diseases’, Costa Rica, 12–13 November. <www.cigionline. org : Publications : Conference Papers and Reports : Leaders’ 20 (L20) Conference Papers and Reports : Infectious Diseases and Global Health> (September 2008). Keusch, Gerald T., Olivier Fontaine, Alok Bhargava, et al. (2006). ‘HIV/AIDS Prevention and Treatment.’ In D.T. Jamison, J.G. Breman, A.R. Measham, et al., eds., Disease Control Priorities in Developing Countries (Washington DC: World Bank and Oxford University Press) <www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=dcp2.chapter.2124> (September 2008). Kuchenbecker, Ricardo (2004). ‘The Inverse Capacity Building Law: From Technical Assistance to Technical Cooperation towards Global Health.’ Paper presented at the conference on ‘HIV/AIDS and Other Infectious Diseases’, Costa Rica, 12–13 November. Centre for International Governance Innovation, Waterloo. <www.cigionline.org : Conference Papers and Reports : Leaders’ 20 (L20) Project : Infectious Diseases and Global Health> (September 2008). ‘Meeting Report.’ (2004). Prepared after the conference on ‘HIV/AIDS and Other Infectious Diseases’, Costa Rica, 12–13 November. Centre for International Governance Innovation, Waterloo. <www.cigionline.org : Conference Papers and Reports : Leaders’ 20 (L20) Project : Infectious Diseases and Global Health : Meeting Summary> (September 2008). 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). Otte, M., R. Nugent, and McLeod A. (2004). ‘Transboundary Animal Diseases: Assessment of Socio-Economic Impacts and Institutional Responses.’ Livestock Policy Discussion Paper No. 9. Food and Agriculture Organization, Rome. (September 2008). Panel of Eminent Persons on United Nations–Civil Society Relations (2004). We the Peoples: Civil Society, the United Nations, and Global Governance. A/58/817, 7 June. (September 2008).
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Price-Smith, Andrew (1998). ‘Contagion and Chaos: Infectious Diseases and Its Effects on Global Security and Development.’ Centre for International Studies Working Paper 1998/001. University of Toronto, Toronto. Price-Smith, Andrew (2008). Contagion and Chaos: Disease, Ecology, and National Security in the Era of Globalization. (Cambridge MA: MIT Press). Soni, Anil (2004). ‘Leaders Summit on Global Infectious Disease: Toward an L20?’ Paper prepared for the conference on ‘HIV/AIDS and Other Infectious Diseases’, Costa Rica, 12–13 November. Centre for International Governance Innovation, Waterloo. <www. cigionline.org : Conference Papers and Reports : Leaders’ 20 (L20) Project : Infectious Diseases and Global Health> (September 2008). Tweed, S. Aleina, Danuta M. Skowronski, Samara T. Savid, et al. (2004). ‘Human Illness from Avian Influenza H7N3, British Columbia.’ Emerging Infectious Diseases, vol. 10, no. 12. <www.cdc.gov/ncidod/EID/vol10no12/04-0961.htm> (September 2008). United Nations Development Programme (1994). Human Development Report. (New York: United Nations Development Programme). United Nations Secretary General (2002). Strengthening of the United Nations: An Agenda for Further Change. A/57/387, 9 October (see also A/58/387/Corr.1). (September 2008). United Nations Secretary General (2005). ‘Secretary-General Appoints Dr. David Nabarro as Senior UN System Coordinator for Avian and Human Influenza.’ SG/A/946. 29 September. New York. <www.un.org/News/Press/docs/2005/sga946.doc.htm> (September 2008). World Health Organization (2005). Avian Influenza: Assessing the Pandemic Threat. Geneva. <www.who.int/csr/disease/influenza/H5N1-9reduit.pdf> (September 2008). World Health Organization (2006). ‘Avian Influenza (“Bird Flu”): Fact Sheet.’ February. Geneva. <www.who.int/mediacentre/factsheets/avian_influenza/en> (September 2008).
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Chapter 7
In-Flew-Enza: Pandemic Influenza and Its Security Implications Yanzhong Huang
Infectious disease has historically affected world politics more extensively than most imagine (McNeill 1976; Watts 1999). Yet despite its impact on the course of history and the fate of nations, for a long time the concept of security focussed on the use of military power to protect national borders and interests abroad. A paradigm shift did not occur until the 1990s, when global health evolved from a humanitarian issue to one of development, governance, and security (Pirages 1996; Garrett 1996; Price-Smith 1999). The nascent field of health security became salient in 2000 when the United States National Intelligence Council (2000) issued its estimate on the threat to U.S. national interests posed by infectious disease. In responding to this new development, countries such as Canada and Japan have explicitly included issues of health security and human security in their foreign policies. In the post– September 11 era there has been a surge of scholarly activity within the field of health and international affairs. A voluminous literature explores the impact of public health problems—framed in terms of human security, health security, microsecurity, or biological security—on national and international security. This chapter is concerned with the effects of a future influenza pandemic on security primarily at it relates to stability both within and among states. Following Richard Ullman (1983), security is defined in a broad manner, covering the pandemic’s potential impact on world economy, sociopolitical stability, and international relations.1 Of course, not all infectious diseases are considered serious security threats—to most, the influenza that costs 36 000 lives annuallly annually in the United States is more a nuisance than a national security concern. To address all infectious diseases as a security challenge not only risks diluting the true meaning of security but also provides policy makers with little guidance for prioritising competing policy objectives (Paris 2001). Uncertainty is another challenge in examining the potential security implications of a future pandemic. While history can be a guide, it cannot foretell the future. In this sense, a straightforward extrapolation from the U.S. experience with the Spanish influenza can be misleading—not only because the world is quite different from 1918, but also because the impact even of a global pandemic will likely vary across countries, economies, and societies. This makes it
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necessary to analyse the nature of the pandemic as well as the context in which it unfolds. After a discussion of the potential characteristics of the pandemic influenza and the international context, this chapter addresses its economic, sociopolitical, and military and strategic implications. It ends with some policy recommendations on how to mitigate the security risks of the pandemic.
How Nasty Is the Bug? Most infectious disease experts agree that the world now stands at the edge of an influenza pandemic (Knobler et al. 2005). While there is no hard science to support that position, an examination of the timeline of influenza over the past 100 years suggests a disproportionate increase in the number of reports of novel sub-types in humans and in the number of animal and bird species involved (Webby and Webster 2003).2 In part, this is because influenza is an RNA virus, which is prone to mutation. According to the World Health Organization ([WHO] 2005), all prerequisites for the start of a pandemic have been met save one: efficient humanto-human transmission. While scientists cannot determine exactly which viruses might cause pandemics, recent outbreaks of avian influenza in Asia make the H5N1 virus the most likely candidate to spark the next influenza pandemic (Lee Jong-wook 2005). Unlike most avian influenza viruses, which emerge briefly and are relatively localised, H5N1 is spreading widely among birds in Asia and has unusual staying power (WHO 2005). A report published in 2005 by the Institute of Medicine of the National Academies (IOM) in the United States called the H5N1 avian influenza in Asia ‘unprecedented in its scale, in its geographical distribution, and in the economic losses it has caused’ (Knobler et al. 2005, 12). It may be just a matter of time before H5N1 adapts to humans, since the virus behind the 1918 Spanish influenza was derived completely from an avian source (Taubenberger et al. 2005). Although the timing of the next pandemic cannot be predicted, efforts have been made to estimate its demographic consequences. The upcoming pandemic will likely resemble the mild influenza pandemics in 1957 and 1968 (both strains were the result of reassortment, meaning an exchange of genetic material between human and avian viruses), which killed 3 million people worldwide. According to research by the Centers for Disease Control and Prevention (CDC), hybrid viruses that combine seasonal human influenza virus and the H5N1 virus fail to spread efficiently, at least in ferrets (Kaiser 2006). It is expected that the longer H5N1 lives in wild birds, the more likely it will become mild (Orent 2005). Modelled on the pandemic of 1968, the best-case scenarios predict that 2 million to 7 million people would die and tens of millions would require medical attention (WHO 2004). Chances are that the next pandemic may not be as mild as the one in 1968. Research on the newly recovered 1918 virus suggests that it completed an avianto-human transfer without gene reassortment, while the number of mutations to get from the avian variant to the human one was relatively small (Taubenberger
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et al. 2005). Moreover, similarities between H5N1 and the 1918 virus (which led to the death of 20 to 50 million people world-wide) have been suggested in the gradual adaptation of an avian virus to a human one, the severity of disease, and its concentration in young and healthy people (WHO 2004). For good Darwinian reasons, pathogens tend to evolve in less lethal directions when mutations allow them to spread more effectively.3 Available evidence, however, seems to point to the spread of a highly transmissible and lethal virus that kills between 80 percent and 100 percent of the birds it infects. By 19 June 2008, it had killed 243 people, with a case fatality rate (CFR) of more than 60 percent (WHO 2008). While such a high CFR is obviously deceptive, the prospect of the emergence of a virulent strain has led at least one public health expert to predict a statistical possibility of as many as 360 million deaths world-wide (Osterholm 2005).4 The potential demographic effects of the pandemic influenza rival a current pandemic, HIV/AIDS. Since 1981, HIV/AIDS has wiped 25 million people off this planet (UNAIDS 2008, 31). Yet unlike HIV, which has an incubation period of up to ten years and spreads gradually from high-risk groups to the general population, a pandemic influenza virus can make a global impact in a matter of months, if not weeks. In the words of John Barry (2005), the 1918 Spanish influenza ‘killed more people in 24 weeks than AIDS has killed in 24 years’. It is therefore necessary to make a distinction between two types of epidemics, outbreak events and attrition epidemics (WHO 1996, 39). The impact of HIV/AIDS as an attrition epidemic is mainly long term, given its long incubation period and the relatively high certainty about its morbidity, mortality, and pathways of transmission. By contrast, an outbreak event like pandemic influenza or severe acute respiratory syndrome (SARS) can generate significant shocks over a very short period, and this impact can be exacerbated by the difficulty to control the behaviour that causes the transmission of the disease. The potential long-term impact of pandemic influenza must not be overlooked, however. After all, the challenge is going to be much bigger than SARS, which killed 916 people and infected 8422 worldwide. Not only is the influenza virus much more contagious and virulent than SARS, but asymptomatic carriers can shed the virus as well, making it difficult to contain its spread through quarantine and isolation.
A Different World The nature of the pathogen is not the sole factor determining the impact of the future pandemic. As works of Alfred Crosby (2003) and John Barry (2004) have suggested, World War I, degree of political commitment, and civil society engagement all affected how the 1918 influenza was transmitted and felt in U.S. society. To the extent that contextual variables matter, an analysis of the impact of the pandemic needs to address the following question: what makes the world of today different from 1918? An easy answer is that there is no world war. During World War I, the conditions of trench warfare on the western front and the American efforts to send troops to the
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battlefield as quickly as possible created an ideal environment for influenza epidemic to thrive (Byerly 2005). Preoccupied with winning the war, political leaders were caught off guard by the disease outbreak, and also had little interest in opening another front to fight the disease. While concerns about morale led to the cover-up of the spread of the influenza, a series of bond-purchasing activities and parades only aggravated the epidemical situation in the United States (Crosby 2003, 53). Today, political leaders are much more conscious than their predecessors about the significant new challenges to the security and prosperity of the citizens over which they preside. As recognised in the United Nations High-Level Panel Report, even though military conflicts between sovereign states remain a major threat, warfare predominantly takes the form of intra-state conflicts (i.e., civil wars), which are closely associated with poverty, environmental degradation, and infectious disease (UN 2004). Drawing lessons from previous epidemics and natural disasters, policy makers have attached more importance to public health, which is being elevated from a ‘low politics’ issue to something salient on their agenda. Indeed, the UN Millennium Development Goals (MDGs) have suggested that health has become a ‘pre-eminent political value’ of 21st-century humanity (Fidler 2005, 184). Political leaders in many countries have demonstrated strong commitment to preparing for the next disease outbreak. According to Laurie Garrett (2005b), the WHO determined that by November 2005 about 60 percent of countries had unveiled some type of pandemic preparation strategy. With advances in biotechnology and widespread use of antiviral drugs, vaccines, and other powerful antimicrobials, the ability to combat pandemic influenza appears to have strengthened. In 1918, these were no antibiotics, no vaccines, no intensive care—indeed, influenza viruses were not known to exist at that time. It is estimated that most of the 1918 deaths were from secondary bacterial infections (not viral pneumonia) that today could be treated effectively by antibiotics (Fumento 2005). Critical gaps nevertheless continue to exist. Many countries do not have sufficient resources to prepare for an influenza pandemic adequately. Despite the growing political commitment and the availability of new medicines and treatments, most countries continue to have weak surge capacity in addressing a pandemic outbreak. A 2006 survey of 183 U.S. cities found that nearly three quarters were not prepared to handle an influenza pandemic outbreak (U.S. Conference of Mayors 2006). International production of most vaccines is still based on the technology from the 1950s, which uses chicken eggs infected with the influenza virus for vaccine development and production. The existing system of manufacturing vaccine is fragile (because chickens themselves could be wiped out in a pandemic) and inefficient (it requires waiting four to six months after the onset of the pandemic, but an outbreak would have to be contained within three weeks). Because of limited production capacity, with this technology only about 14 percent of the world’s population would be vaccinated within a year of the pandemic (Osterholm 2005). As with antiviral drugs, by October 2005 40 countries had ordered Tamiflu, yet the orders take considerable time to be processed and delivered. There is a huge gap between developed and developing countries in terms of the capacity of preparing
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for the pandemic. Most of the world’s influnza vaccine is produced in only nine developed countries, with Europe producing 70 percent of the world’s vaccines. Access to vaccines in the rest of the world is thus limited, especially countries in the developing world: countries with production facilities may limit or ban the export of vaccine to other countries after the onset of the pandemic (‘Preparing for a Pandemic’ 2005). The lack of health system capacity is particularly a problem in front-line countries, such as Vietnam and Indonesia, where lack of financial support has already compromised government capacities in containing the spread of bird influenza (Bradscher 2005). In still other countries such as China, where rural people lack access to health care and incentives to cover up remain strong, a disease outbreak could quickly be out of control and spread around the globe before the international community even became aware of it. The likelihood of a rapid spread of infectious disease is related to another important development: globalisation. A centuries-old dynamic, globalisation today is different in that it features the rise of new tools, new actors, new rules, and new markets (United Nations Development Programme [UNDP] 1999, 30). With the spread of democracy and civil society groups, the emergence of global networks of nongovernmental organisations (NGOs), and the availability of new tools such as the internet, cellular phones, and media networks, more direct power is given to individuals than any time in history (Friedman and Ramonet 1999). As a result, a complete government information blackout becomes not only impossible but also counterproductive (see Huang 2004). Meanwhile, globalisation leads to the adoption of new rules that become more binding for national governments. In May 2003, in response to SARS, the WHO was formally authorised to garner and analyse data from non-state actors and to issue global alerts when international public health was threatened by an infectious disease. Given that states historically have sought to suppress the flow of information regarding endogenous epidemics, the use of non-state information sources will expedite the flow of information to the WHO, and therefore strengthen its outbreak alert and response activities. In May 2005, the World Health Assembly (WHA) adopted the revised International Health Regulations (IHR), which provide an international legal framework for preparedness for and responses to outbreaks. With the new IHR, the WHO has a clearer framework to provide leadership on public health emergencies. In this sense, globalisation promises to increase international disease surveillance capability and mitigate the consequences of the pandemic when it occurs. Yet globalisation is a double-edged sword. While the tools of globalisation can be used to expose cover-ups and report disease outbreaks in a timely fashion, they can also be used to spread panic, thus magnifying the negative impact of the disease. Indeed, as ‘the shrinking space, shrinking time and disappearing borders’ link people’s lives ‘more deeply, more intensely, more immediately than ever before’ (UNDP 1999, 1), the vulnerability to disease outbreaks has only increased. As Singapore’s senior minister Lee Kuan Yew (2004) observed, in earlier times new viruses would have killed nearby villagers, but then the danger would have passed; with much greater and faster movement of people and goods, the viruses travel swiftly and far.
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Even before commercial air travel, the Spanish influenza managed to circumnavigate the planet five times in 18 months. It would certainly take much less time for it to wreak havoc world-wide today. Indeed, virtually any city in the United States today can be reached by commercial flight within 36 hours, less than the incubation period for most infectious diseases. As the distinction between domestic and international public health is blurred, so is the difference between national and international economy. The increasing linkage of economic entities by production, marketing, and investment means that a disease-caused economic shock in China can be felt immediately in other parts of the world. Since globalisation is a process integrating not just markets but culture and governance, the impact will go beyond the economic sectors and have important implications for sociopolitical and international stability. Other changes since 1918–19, such as population explosion, have made pandemic influenza a greater threat, not a lesser one. Between 1918 and 2008, the world population increased nearly four fold, from 1.8 billion to 6.7 billion. Meanwhile, the percentage of population at risk for secondary infection caused by a pandemic influenza is growing rapidly, as the population today includes more elderly and more people with a weakened immune system (owing to aging, immunosuppressive medication, and concurrent infections such as HIV infection) (Osterholm 1996). HIV/AIDS poses a particular challenge to mitigating the consequences of the pandemic influenza. If a pandemic influenza arrives, it will be the first time for humans to experience two pandemics at the same time. While still unsure of how H5N1 will interact with the HIV virus, scientists speculate that because of the immunosuppression associated with the infection, HIV-positive populations either will be rapidly devastated or will serve as ‘an ambulatory Petri dish’, incubating and possibly spreading new forms of the virus (Garrett 2005b). Such demographic changes, coupled with urbanisation and exponential growth in foreign travel, have made significantly more people vulnerable to the risks of infectious diseases, including a influenza pandemic. In sum, the world is different from that in 1918. While certain factors (e.g., increasing political commitment) could reduce the negative impact of the pandemic influenza, other developments (e.g., lack of surge capacities, growing interdependence, and population explosion) can make the influenza pandemic much more devastating than ever before. In any case, the impact of the pandemic can still be considerably lessened, provided that political leaders recognise the economic, sociopolitical, and international threats that the pandemic poses and responds accordingly. The remainder of this chapter will explore the implications of the pandemic influenza in all these three dimensions.
Effect on World Economy In An Essay on the Principle of Population, Malthus (1798) posited that disease served as a ‘positive check’ of population growth by affecting food supply growth. The role of disease as a great population regulator was demonstrated by the bubonic
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plague (Black Death) in the 14th century, when the drastic depopulation resulted in decades of continent-wide crop and livestock deficiencies (Herlihy 1997). Contemporary epidemics such as SARS led to a substantial decline in consumer demand, especially for travel and retail sales services. According to the World Bank, SARS caused an immediate economic loss of about 2 percent of East Asian regional gross domestic product (GDP) in the second quarter of 2003 (Brahmbhatt 2005). An estimate made by Bio Economic Research Associates placed the cost of SARS to the global economy as high as US$50 billion (Newcomb 2005). Most economic analysts agree that depending on the severity of the disease and sustainability of its impacts, spread of an influenza pandemic would take a much heavier toll on the national, regional, and global economies. The World Bank estimates that the global costs could reach US$800 billion in one year (see Table 7-1). A report published by Conference Board of Canada (2005) claims that a large-scale influenza pandemic would ‘throw the world into a sudden and possibly dramatic global recession’. Another report from BMO Nesbitt Burns concurs, stating that the pandemic’s economic impact could be ‘comparable, at least for a short time, to the Great Depression of the 1930s’ (Cooper and Coxe 2005). All these estimates and predictions suggest a negative dynamic between infectious disease and the economy. In reality, though, the economic impact of epidemics is much more complex than originally thought. As Maureen Lewis (2001) pointed out, apparently obvious microeconomic effects might not be reflected in macroeconomic Table 7-1: Estimates of the Economic Damage from Pandemic Influenza
Scope
Estimated economic damage US$88 billion to US$206 billion in current dollars
Comments Assumes 89 000–207 000 deaths and 314 000– 734 000 hospitalisations in the U.S.; excluding disruptions to commerce National and society (United States) US$181 billion in direct and Not including disruptions indirect health costs (for a in trade and other costs to moderate pandemic with business and industry no interventions); US$450 billion (worst-case scenario) US$113.4 billion or 2.6% of Assumes an attack rate of regional GDP (mild shock); 20% and a case fatality Regional US$296.9 billion or 6.8% rate of 0.5%; does not (Asia) of regional GDP (severe include disease-associated shock) medical costs Total costs could reach Assumes a case fatality Global US$800 billion in one year rate of less than 0.1% in the U.S. Note: GDP = gross domestic product.
Source Centers for Disease Control (Meltzer et al. 1999)
U.S. Department of Health and Human Services (2005)
Asian Development Bank (Bloom, de Wit, and CarangalSan Jose 2005, 6–7, tables 1, 2) World Bank (Brahmbhatt 2005; Newcomb 2005)
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data: the relationship between the costs inflicted at the micro level and those on the society in aggregate can vary considerably across epidemics. A disease that kills the weak and the very young can even have the perverse effect of raising the GDP per capita, provided that those at the most productive ages survive but there are fewer people in total to share the wealth (‘Epidemics and Economics: The Economic Consequences of Disease’ 2003). This provides yet another reason to explore the nature of a forthcoming pandemic. To be sure, each influenza outbreak is different and it is not possible to predict what groups will be at highest risk (Simonsen et al. 2005). Given the broad similarity between the 1918 virus and the H5N1 virus, however, the pandemic influenza is expected to be different from a typical influenza that strikes hardest among the elderly, the very young, and people with underlying chronic conditions. Instead, the pattern of the pandemic-induced population shock is likely to take a ‘W’ shape because of its devastating impact on the economically active population in addition to the very young and the elderly.5 In the latter case, half of those killed in the pandemic could be between the ages of 18 and 40 (Osterholm 2005). The sickness and premature deaths of income earners have important implications for economy at the micro level. Disease-associated medical costs and the value of workdays lost due to the illness reduce the disposable income for households. As savings are replaced with current expenditures, the rate of capital accumulation (savings and investment) declines. The more lethal and contagious the virus, the more bread earners will get sick or die, and the higher the number of households that will be pushed below the poverty line. The pandemic thus reinforces income inequality, since poorer households bear a much greater economic burden as a result of infection than their wealthier counterparts. As demonstrated in the HIV/AIDS pandemic, because of the loss of family members and sales of assets to pay healthcare costs, many poor households may never recover their initial income (Cohen 1997). For firms, the reduction in labour due to incapacity and mortality would increase wage and replacement costs, forcing many to increase the prices of their products. Likewise, the costs inflicted upon individual households and firms will contribute to economic shocks at a macro level. Like SARS, the influenza pandemic will affect consumer confidence and alter consumption and social patterns. Yet unlike SARS, where the main impact was on the demand side (Fan 2003), an influenza pandemic will cause supply shocks by affecting the health of the labour force. Research suggests that if 25 percent or more of a population is infected, fuel and food supplies will be significantly reduced, which will deal a serious blow to the economy unless effective measures are taken to maintain basic services with a reduced labour force (Coulombier and Ekdahl 2005). The U.S. Homeland Security Council (2005, 13) predicts that at the peak of an influenza pandemic as many as 40 percent of workers in U.S. firms could be absent, including those who are sick, people who need to care for others, and people who stay home because of safety concerns. Depending on the epidemiological features and the psychological impact of the pandemic, the demand and supply shocks will vary. In general, the more pathogenic and contagious of the virus, the greater the supply shock (due to higher level of
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absenteeism of otherwise healthy workers) and demand shock (due to reduced consumer confidence and activities). The impact of the pandemic on demand, though, may not be always negative. As happened with the bubonic plague, with a high attack rate and a high CFR, people in the affected regions may discount their future so heavily that they adopt a today-we-drink-for-tomorrow-we-die attitude, leading to an increase in consumer demand (Hays 1998). Also, the longer the psychological impact of the outbreak lasts, the more significant reduction it may cause in consumption and export of services (as consumers in directly affected countries reduce their activity, and as the rest of the world reduces its consumption, affecting trade and investment). Assuming that the psychological impact of the outbreak lasts longer and seriously affects demand for one year, the Asian Development Bank (ADB) placed the estimated loss of nine Asian economies at approximately 6.5 percentage points of GDP in 2006, which means that growth in the region would essentially come to an abrupt halt (Bloom, de Wit, and Carangal-San Jose 2005). A battered regional economy will result in significant disruptions to the highly integrated global economy. Difficulties in trade and travel are likely to interrupt the flow of goods and services, ‘with cascading effects in industries with tightly linked supply chains that depended heavily on supplies in the affected countries’ (Newcomb 2005). Indeed, most of the cost of the SARS epidemic was incurred not by its direct economic impact (i.e., the medical treatment costs and lost productivity associated with absenteeism) but by the indirect economic impacts such as disruption of trade, travel, and investment, the interruption of product supply lines, and fear-induced behavioural changes in consumers, travellers, and businesses (Newcomb 2005). A well-connected world economy is very sensitive to exogenous shocks. According to the ADB, if a disease outbreak leads to the shut-down of the Asian economy, global GDP will contract 0.6 percent and the global trade of good and services will shrink about 14 percent (with a total cost of $2.5 trillion) (Bloom, de Wit, and Carangal-San Jose 2005, 5). With foreign companies shifting manufacturing to China that country has become a workshop for the world. A world economy that depends so heavily on China as an industrial lifeline can become increasingly vulnerable to a major supply disruption caused by a pandemic outbreak in this country. Additional secondary effects on the economy are equally important. First, if people avoid social contact, epidemics could adversely affect labour productivity due to restricted labour mobility (which inhibits labour from moving to where it is most productive) (Jong-Wha Lee and McKibbin 2004, 95). Second, fear and uncertainty may lead people to rush to purchase daily necessities, and this panic buying threatens to trigger a ‘bank run’ that could disrupt seriously a country’s financial industry. Third, it is likely that government and international response to the disease (e.g., quarantines, import bans) exacerbates the economic impact by sustaining the psychological impacts and reinforcing a tendency for markets to overreact. If the pandemic lasts longer than a year, quarantines could lead to widespread business failures, mass unemployment, and further decline of consumer demand. The impact of pandemic influenza is unlikely to be the same for all economies. Quarantine-induced economic shocks in an affected country, for example, may
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depend on the country’s economic size and global importance. David Fidler (2005) has suggested that countries would be more willing to restrict trade and travel aggressively with Indonesia than with China because of the latter’s sheer market size and importance in global economy.6 The SARS outbreak suggests that open economies, economies that are significant exporters, and economies with a prominent service sector are particularly vulnerable to international economic shocks (JongWha Lee and McKibbin 2004, 95). The connection between open economies and short-term economic shocks is suggested in Table 7-2. By taking into account the openness of the economy and healthcare costs, Bio Economic Research Associates developed a composite index to measure the relative economic risk of influenza pandemic in selected countries. According to this index, China, Hong Kong, and Singapore are the Asian economies most exposed to the risk of the pandemic, and the U.S. is the most vulnerable among five members of the Organisation for Economic Co-operation and Development (OECD) assessed (Newcomb 2005, figure 4). In emphasising the significant negative dynamics between infectious disease outbreaks and economic prosperity, however, short-term impact during the pandemic is often not differentiated from the impact in the immediate aftermath of the pandemic. While in general the short-term impact is negative during the pandemic, in the aftermath it may not be entirely negative. The Spanish influenza, for example, did not lead to a drop in per capita income growth across the U.S. in the 1920s, nor did it have any significant impact on acreage sown per capita in India (Crosby 2003). Indeed, a study of its effects on the growth of income per capita in the U.S. between 1919 and 1930 revealed that the states with the highest mortality rates and highest business failure rates grew fastest (Brainerd and Siegler 2003; quoted in ‘Epidemics and Economics: The Economic Consequences of Disease’ 2003). In Table 7-2: Total Exports as Share of Gross Domestic Product and Estimated Economic Shocks
Economy Singapore Hong Kong Malaysia Thailand Korea Philippines China Indonesia
Total Exports as Share of GDP 258.3 186.8 125.4 68.2 56.4 48.9 45.2 42.0
Estimated Reduction in Annual GDP Growth, 2006 (percentage points) 22.8 17.5 11.3 11.7 6.3 3.0 5.3 2.8
Notes: The economic shocks include both demand and supply shock. The estimate assumes four quarters of strong demand contraction globally. GDP = gross domestic product. Source: Bloom, de Wit, and Carangal-San Jose (2005).
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2003, the containment of SARS was followed by swift and strong economic growth in Asia, particularly China (Doven 2003). The potential of economic rebound in the immediate aftermath of the pandemic cannot be denied, although the speed and strength of the economic revival may depend on the duration of the pandemic and the damage it does to the manufacturing sector (Newcomb 2005). Although an influenza pandemic is described as an outbreak event and its economic impact is likely to be mainly short term (as with SARS), its long-term economic consequences cannot be dismissed. Unlike SARS, a pandemic can lead to significant drop in physical capital (due to reduced investor confidence in the future of the affected economies) and human capital (as a result of mass morbidity and mortality). The destruction of human and physical capital will reduce an affected economy’s long-term economic growth potential. A study by Douglas Almond (2006), with the support of the National Institutes of Health and the National Institute of Aging in the U.S., suggested a broad spectrum of persistent effects of the 1918 Spanish influenza: cohorts in utero during the height of the pandemic typically displayed reduced educational attainment, lower socioeconomic status, and increased rates of physical disability. It also found that ‘persons born in states with more severe exposure to the pandemic experienced worse outcomes than those born in states with less severe pandemic exposures’. While there are no solid data to examine a pandemic’s long-term impact on investment, it is not hard to imagine that if the pandemic persists in an affected country and begins to disrupt global production lines, multinational corporations (MNCs) will be forced to reconsider their investment strategy. The increased risk profile in doing business in an affected country will reduce foreign investment and exports, which will eventually hurt the manufacturing sector. Nonetheless, human societies and economies can be highly resilient in the long run. A negative shock to population growth caused by the bubonic plague, for example, actually led to faster accumulation of capital and subsequently faster output growth. The scarcity of labour in the century after 1350 also encouraged more technological innovation (for example, the rapid spread of water mills and windmills in Europe; see Hays 1998). To summarise, a pandemic can cause tremendous damage to a highly interconnected global economy. Depending on the nature of the pandemic and its international context, the impact can vary considerably across economies, and there can be wide variation between its immediate impact and its impact in the immediate wake of the outbreak, as well as between its short- and long-term effects.
Sociopolitical Stability The onset of an influenza pandemic will combine with economic instability and other factors to create volatile social and political situations. Uncertainty about the nature of the disease could produce significant worry, anxiety, fear, panic, and even mass hysteria in an affected society. As suggested during the SARS outbreak, government mishandling of an outbreak can intensify the fear and facilitate the spread
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of rumours, pushing the panic to an even higher level. Because of its psychological effect, a disease outbreak often acts as a multiplier factor on social stability. During the plague outbreak in Surat, India, in 1994, for instance, the fear of an epidemic was so intense among the city residents that within four days, one quarter of the population fled the city (World Resources Institute 1996). While only 56 people died nationwide, the outbreak and mass exodus generated considerable anxiety throughout India and the world, with the fear that plague might be transported far and wide by Surat refugees. Historical cases also suggest that the fear factor associated with a pandemic can be as potent and destructive as the virus itself. During the bubonic plague, Jews were commonly accused of spreading the disease and therefore subject to mass killings as a part of the hysteria (Hays 1998, 50). During the SARS outbreak, disease-associated stigma and discrimination were reported in countries including China, Canada, and the United States. According to a survey conducted during the outbreak by the Harvard School of Public Health, 16 percent of Americans avoided people whom they thought might have recently travelled to Asia, while 14 percent shunned Asian restaurants and stores (Stein 2003). This problem may be amplified in a future pandemic, because people will be advised to minimise, if not avoid, social interactions. As the pandemic becomes part of a national lexicon, rumour, suspicion, and misinformation could lead to profiling and discrimination against people from or associated with the affected regions. If Asia turns out to be the epicentre of the next pandemic, it is likely that every immigrant or visitor from the region will be viewed as a Typhoid Mary. Government measures such as forced quarantine will only reinforce the vicious cycle of discrimination against this group, who will be perceived as diseased or dangerous. Such xenophobia and racism could be used by the politically ambitious to influence election outcomes. While the potential dangers in this scenario should not be exaggerated, the 2002 presidential election in France highlights the danger of such an issue being exploited by political extremists to challenge the foundation of a liberal democracy (Huang 2003). The psychological impact and changing social pattern will increase the likelihood of lawlessness and violence by fostering more intense rivalries between different ethnic and religious groups, between the socially privileged and the marginalised, and between state and society. Pandemic-induced mass unemployment and rising income inequality could bring to the surface long-standing grievances of haves against have-nots and intensify the conflicts between different classes and groups. The bubonic plague, for example, increased the tensions between the rich and poor in Europe, leading to peasant riots in England, France, Belgium, and Italy (Hays 1998). In the meantime, the pandemic may be so overwhelming that people with shortened time horizons could engage in all kinds of risky behaviour (such as crimes and riots). As documented by Thucydides, the plague of Athens in the fifth century BC triggered ‘a state of unprecedented lawlessness’ because ‘men, not knowing what would happen next to them, became indifferent to every rule of religion or law’ (Thucydides 1952, 155). Protests and riots also occurred in China during the SARS outbreak. In late April 2003, thousands of residents of a rural town near Tianjin
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ransacked a building they believed would be used to house potentially ill SARS patients (Eckholm 2003). The need for a capable state to respond effectively to the spread of disease and the social problems that flow from it occurs at a time when the capacity of the state is reduced by the pandemic. Added to the likely labour shortages among government employees, staff fatigue and loss of institutional memory are associated with high staff turnover. By debilitating law enforcement agencies and by decimating the ranks of skilled administrators, the pandemic will not only cause policy consistency and enforcement problems, but will also diminish the reach or responsiveness of government institutions, or reduce their resilience. In addition, the pandemic could compromise the state capacity to respond adequately to the pandemic by affecting elite or election politics. History is full of examples of the political instability triggered by disease-caused deaths among reigning families (McNeill 1976, 260). In China during the SARS crisis, conflicts over how to respond to the disease outbreak exacerbated factionalist politics and contributed to initial policy immobility (Huang 2004). The reduced ability of the government to respond can only foster public discontent with the government and create greater pressures on government structures (Chemical and Biological Arms Control Institute [CBACI] and Center for Strategic and International Studies [CSIS] 2000). As the pandemic may increasingly highlight a government’s incapacity in crisis management and in providing adequate public and health services, the government would face legitimacy problems—meaning its ability to have its rule accepted by the populace and political opposition will be eroded. This negative synergy between state and society would make it even more difficult to break the downward spiral of disease, social instability, and weak government structures. As suggested by China’s experience with SARS, confused and shocked people may turn to non-state sources of moral authority and spiritual well-being.7 In the worst scenario, poor government response could embolden a political opposition that resorts to violence in an attempt to topple the government (CBACI and CSIS 2000, 11). Will the pandemic lead to social breakdown? In examining the impact of the Spanish influenza on the U.S. society, John Barry (2004, 350) suggested that society began to break apart because ‘a fear and panic of the influenza akin to the terror of the Middle Ages regarding the Black Plague, [was] prevalent in many parts of the country’. Noting that doctors and nurses were kidnapped and victims were starving to death ‘not from lack of food but because the well [were] afraid to help the sick’, Barry (2005) suggests that if the pandemic had continued to build, ‘civilization could easily disappear from the face of the earth within a few more weeks’. However, even during the pandemic, the psychological and sociopolitical impacts of a pandemic on individuals and societies can be very mixed. Psychologically, fear and panic over a disease outbreak often coexist with passion for the sick and poor; socially, mass hysteria and social discrimination of infected persons are often juxtaposed with social cohesion and collective problem solving (Chan 2003). In contrast to Barry’s pessimism, Alfred Crosby (2003, 115) observed a picture in which the pandemic actually increased social cohesion in the United States: despite the deep schism in
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the society, ‘Americans did lend each other a helping hand’. Even with ‘occasional harshness’, the 1918 influenza pandemic did not demonstrate a general pattern of race or class antagonism. Similarly, in the political sphere, the dynamics among disease, instability, state capacity, and political legitimacy may not be entirely negative. The U.S. government cover-up and inaction during the Spanish influenza did not cause any legitimacy problems for the government (Crosby 2003, 115). In fact, even with its disruption to U.S. society, the pandemic did not seem to have had a significant impact on fundamental governmental and social institutions. While contextual factors such as World War I played an important role in this process, enthusiasm from a robust civil society offset the government capacity deficit in the battle with the influenza (Crosby 2003, 115–116). The mixed political outcome was also shown in the case of SARS in China. Despite the initial cover-up and inaction, the Chinese government’s ability to contain the spread quickly shored up its legitimacy (Huang 2004). Meanwhile, the SARS debacle opened a political window for central leaders to reinforce control over lower-level officials and to pursue a more balanced development agenda. Even in the absence of an autonomous and civil society, strong state capacity helped the government to weather the most severe sociopolitical crisis facing the Chinese leadership since the 1989 Tiananmen crackdown. Both cases suggest that the socioeconomic impacts can vary, depending on the level of civil society engagement and state capacity in battling the pandemic (see Table 7-3). As suggested in Table 7-3, the ideal outcome is that a strong state works closely with a robust civil society to contain the spread of the pandemic and mitigate its potential sociopolitical outcomes. ‘Strong state’ means high state capacity to respond not only on the health front but more generally (e.g., ability to maintain social order and to provide essential commodities and services). State capacity is more Table 7-3: State Capacity, Civil Society Engagement, and Sociopolitical Impacts
High
Low
High
Negative sociopolitical consequences minimised
Coexistence of social dislocations and social cohesion/cooperation; no fundamental change in sociopolitical structures (e.g., the United States during the Spanish influenza)
Low
Civil society engagement
State Capacity to Respond
Initial dislocations in the society and polity likely, but mitigated by strong and effective state engagement later (e.g., China during SARS)
Negative downward spiral among pandemic, sociopolitical instability, state capacity, and political legitimacy; social breakdown or state failure highly likely
Note: SARS = severe acute respiratory syndrome.
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effective if it partners with a robust civil society. With a well-developed pandemic preparedness plan, a consolidated democracy can have the potential for the bestcase scenario. The negative spiral is most intense in countries where state capacity is already severely limited yet effective civil society engagement is not expected. In such a situation, countries have few human, financial, and other resources from which to draw to break the negative spiral, and the pressures on the already fragile or weak governments can cause them to collapse. While it is difficult to predetermine state capacity to respond and the level of civil society engagement, some countries in southeast Asia or sub-Saharan Africa might well become victimised by this scenario. The situation might be even worse in sub-Saharan Africa, where governments are fragile and burdens of HIV/AIDS are heavy. Given the similarity between the H5N1 and 1918 viruses, and the fact that both the 1918 Spanish influenza and HIV/AIDS typically attack individuals in the prime of their economically productive lives, it is highly likely that the spread of pandemic influenza to East Africa would quickly destroy the regional economies, exacerbating the humanitarian crisis. Fuelling this death, destitution, and destruction are the discontent of excluded, disadvantaged, or repressed groups and the greed of warlords, which could lead to a Hobbesian world of a war of everyone against everyone. In short, the onset of the pandemic has a strong potential to cause sociopolitical dislocations in affected countries and set in motion a vicious cycle among disease, social stability, and state capacity. The sociopolitical impacts nevertheless can be mixed and may vary across countries, depending on the state capacity to respond and the effectiveness of civil society engagement. The negative consequences can be minimised or mitigated in countries with a strong state or a robust civil society engagement. By contrast, the negative dynamics are very likely to lead to social breakdown or state collapse in countries where state capacity is already severely constrained and a robust civil society engagement is absent.
Military Security and International Stability In Leviathan, Thomas Hobbes claimed that the central functions of the state are to protect its citizens from both internal and external forms of predation. The presence of a pandemic influenza will not only limit state capabilities to impose sociopolitical order, but will also jeopardise state capabilities to fend off external aggression. According to Crosby (2003, 11), the Spanish influenza killed ‘nearly as many American soldiers as died in battle, ten times and over that number of American civilians, and twice as many people in the world as died in combat on all fronts in the entire four years of the war’. Through the debilitation of military personnel, the pandemic can degrade human resources and reduce force strength. Provided that the future pandemic influenza resembles the 1918 influenza in that the adult males who were most vulnerable were those of military age (who are also the most susceptible to secondary complications such as pneumonia), the pandemic will also jeopardise the pool of physically qualified candidates for the new recruits. Meanwhile, the spread
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of the pandemic will soon create an immunosuppressed military force, which by its very nature will be highly vulnerable to biological and chemical weapons. Military readiness and capabilities can be further compromised when the burden of disease generates costs that limit defence budgets (CBACI and CSIS 2000). For states that are already in political chaos, even the perception of a weakened military can make them susceptible to foreign aggression. It is noteworthy that pandemics historically had little effect on humankind’s desire to make war. Striking at the very heart of the Hundred Years War, the Black Death saw the continuous search of Edward III of England for the human resources and treasure to sustain the war with France (Bray 1996, 69). Similarly, Woodrow Wilson insisted that the lives lost to the Spanish influenza must be balanced against those that could be saved with a speedy end of World War I. By depleting the number of troops available for combat and support, the pandemic also has the potential to affect military operations, even war outcomes. In her testimony before the U.S. Senate Committee on Foreign Relations, Laurie Garrett (2005b) asked this question: If a nation is fighting wars on two fronts involving more than 200,000 troops, and H5N1 turns out to mirror the 1918 flu in that it takes its highest toll among young adults, how can the armies continue to carry out their operations? If, in addition, their enemy practices suicide bombings, and therefore cares not whether it is infected with a deadly virus, how might the pandemic affect the course of the wars?
The 1918 Spanish influenza provides the most recent case to examine the impact of the pandemic on the course of war and war outcome. The pandemic slowed perceptibly military operations on both sides. It forced the British troops to postpone their scheduled attack on La Becque and made it harder for the Germans to advance and harder to retreat (Crosby 2003). The pandemic nonetheless did not stop military operations, nor did it affect the final outcome of the war (largely because a pandemic usually affects each side equally) (Crosby 2003). Provided that neither side of the conflict enjoys ‘epidemiological superiority’ (McNeill 1977), the future pandemic is less likely to become a significant contributor of the final outcome. That being said, in certain cases ‘differential immunity’ did exist and made military forces from certain countries more susceptible to an infectious disease (Kelley 2000). The military effect of this differential immunity has been well recorded in the past. For example, the plague of Athens affected the course and outcome of the Peloponnesian War by devastating Athens but not the Peloponnese. Owing to differential immunity, the Old World epidemics became the ‘strongest ally’ and ‘deadliest weapon’ of the Spaniards in conquering the Aztec and Inca empires (Karlen 1995, ch. 7). While the armed forces of the U.S., Canada, and other developed countries are among the best trained and organised in the world, the fact that their soldiers grow up under good hygienic conditions also means that they are at more risk of contracting exotic pathogens from foreign military theatres than members of many potential opposing forces who spend their childhood in hygienic squalor (Kelley 2000). If the upcoming pandemic
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indeed features this differential immunity, forces from developing countries can pose a significant health threat to those from developed ones, which can affect the course of war. The pandemic has important implications for regional stability as well. First, some of the countries that are likely to be most affected by the pandemic, such as China and Indonesia, are significant regional or global players in international politics. Indonesia, with the largest Muslim population, has played a crucial role not only in the global efforts against international terrorism but also in sustaining regional stability. Second, political leaders in authoritarian states might choose to engage in foreign excursions to deflect public attention from domestic sociopolitical turmoil caused by the pandemic. Alternatively, dictatorship can be strengthened in certain countries as the leaders embrace hyper-nationalism to rally the masses and restore political order. Third, the pandemic could inhibit the military’s ability to participate effectively in international peacekeeping. On the one hand, the pandemic may reduce a contributing state’s willingness to participate in peacekeeping operations, especially in countries that are suffering high morbidity and mortality because of the pandemic. On the other hand, states may become less willing to host peacekeeping missions when troops from affected countries are seen as vectors for the proliferation of the pandemic. As a result, international ability to enforce peace agreements or ceasefires will be compromised, and this could rekindle international conflicts or civil wars in flashpoint regions. Government and international response to the pandemic can potentially be politicised and can have important implications for North–South relations. Quarantines or restrictions on trade imposed by the developed countries could exacerbate socioeconomic crises in those countries. In addition, because most of the drug patent holders are in the developed countries, apathy toward sharing patents, antiviral drugs, or vaccines with the developing world will fuel hatred and resentment against the North. Populist leaders in the South may find it expedient to blame the North for their own lack of capacities in handling the outbreak. Strained North–South relations could play into the hands of international terrorism and further destabilise the western world. The pandemic influenza is also set to be a factor in the very balance of power in the world. The proliferation of the virus can lead to changes in power in both absolute and relative terms. In absolute terms, the pandemic-induced effect on physical and human capital as well as on fighting capabilities will change a state’s level of power over the long run, if power is measured in terms of GDP or military strength. In relative terms, since the economic and sociopolitical impacts vary across states and economies, some states will suffer less damage than others and therefore enjoy an advantage in the relative distribution of capabilities between states. History abounds with cases of infectious disease outbreaks unsettling the balance of power and changing the international and strategic landscape. The Plague of Justinian led to the collapse of Byzantine Roman Empire in the sixth century. Black Death intensified military exposure to disease, especially to bubonic plague, and was considered a real factor in undermining Mongol military might in the 14th century (McNeill
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1977). Black Death also had a devastating impact on the fortunes of the city-state of Venice, reducing it from a regional power to a ‘museum city’ (Watts 1999, 20–21). In a somewhat more recent case, infectious disease contributed to the collapse of an entire imperial holding. When Napoleon Bonaparte attempted to regain control of Haiti in 1802, the French army was struck by a combination of Haitian resistance and yellow fever, so that by the following year he had abandoned the French claim altogether (Hays 1998, 205). Epidemics nonetheless have had little or no effect upon institutions when they were on the rise, as in the Roman Empire (Bray 1996, 11). Given this line of reasoning, it is likely that a truly global pandemic would accelerate the global shift of balance of power in the favour of China or India, at the expense of the United States.
Policy Recommendations Predicting the impact of an impending pandemic influenza is a risky business for two reasons. First, a prophecy itself can be self-fulfilling. In the words of Thomas Schelling (1960, 91), ‘what is most directly perceived as inevitable is not the final result but the expectation of it, which, in turn, makes the result inevitable’. In this sense, the publication of alarmist reports would only reinforce the widespread expectation of a catastrophe and this expectation can create a vicious downward cycle between pandemic and international stability as predicted by scaremongers. As the Nobel Prize–winning virologist David Baltimore (2003) observed during the SARS epidemic, the ‘media-transmitted epidemic of concern for personal safety’ could outpace the risk to public health from the actual virus. This chapter provides a balanced, history-related, and science-based analysis of the security implications of the pandemic. It suggests that the upcoming pandemic threatens to set in motion a series of developments that will slow economic growth, endanger social stability, hurt political legitimacy, and compromise military readiness. But it also conveys the message that the relationship between pandemic influenza and international stability and security is a very complex one. First, the immediate impact of the pandemic on economy, society, polity, and security can be mixed even within an affected country. Second, the impact can vary across countries, economies, and societies due to a confluence of factors, including the nature of the disease and the context in which it exists. Third, a distinction should be made between its impact during the pandemic and that in its immediate aftermath, between short-term and long-term impacts, and between its direct consequences and its secondary effects. Another problem is the stakes involved in predicting the impact of the pandemic. There will be a pandemic, but no one knows when it will come, what its origin will be, and where the first outbreak will occur—indeed, even today there is no clear idea about the origin of the Spanish influenza. Policy makers preparing for the pandemic therefore face a constant political dilemma: how can governments justify committing already scarce public health and other resources to an unpredictable but potentially catastrophic event? Very often, the political and economic stakes are so
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high that politicians choose to err on the side of caution. In 1976, when facing a potential swine influenza outbreak that promised to kill 1 million Americans, the Ford administration decided to inoculate every man, woman, and child in the United States. The administration paid dearly for this decision. The swine influenza never occurred. The direct cost of the campaign notwithstanding, the U.S. government ended up paying claimants some US$90 million for taking over companies’ liability. The episode also weakened U.S. government credibility in public health and helped undermine the political stature of President Gerald Ford (Garrett 2005a). Decision makers sometimes can be so overwhelmed by the consequences of being wrong that they may not be able to tell the difference between consequences and likelihood, which can lead them to make ‘wrong’ decisions in disease preparation. The varied impact of the pandemic and the experience with the swine influenza are no excuse for complacency or inaction. What this chapter suggests is that economic, sociopolitical, and security costs incurred by a pandemic can be mitigated, if not avoided, by a holistic and harmonised strategy featuring high-quality surveillance, transparency, effective pharmaceutical and non-pharmaceutical interventions, mobilisation of civil society, and international cooperation. An effective strategy should include the following elements: • reorienting the security policy agenda from warfare to welfare. This means committing significantly more resources to areas of immediate concern to the people, and also paying more attention to the poor, the weak, and the pariahs, who are at particularly high risk for infectious diseases; • expanding government surge capacity to respond to public health emergencies, and more generally to ensure the provision of basic public goods and services during an outbreak; • encouraging the active engagement of civil society groups (e.g., NGOs promoting public health, local communities) in pandemic preparation; • improving risk communication with the public. Effective communication entails providing the public with scientific information about the disease, its spread, and its consequences in an honest and timely manner; • narrowing the critical gap between the developed and developing countries in pandemic preparation. For developed countries, this means sharing with developing countries, especially those front-line states, their experiences, technologies, vaccines, and antiviral drugs in combating pandemic influenza. There should be a regional network to coordinate the distribution of antiviral drugs and vaccines and ensure the demands of countries in most need are met swiftly; • prioritising the needs of different age and occupational groups in the allocation of vaccines and antiviral drugs to maximise the survival rate yet minimise the impact on the economy, governance, and security. Special attention should be paid to the military and police, healthcare workers, officials in key posts, workers in their most productive years, and pregnant women; • coordinating international and government responses to outbreaks to reduce disruption to the world economy caused by restrictions on travel and trade; and
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• balancing the need to fight an impending influenza with other infectious diseases, such as HIV/AIDS, to minimise the cost of the interaction of different pathogens. Ninety years ago, when the Spanish influenza was wiping out populations across the globe, children in the United States used to sing: I had a little bird And its name was Enza I opened the window And in-flew-enza. Today, the window is open again. The difference is that by acting now and working together, it is possible to turn it into a window of opportunity to strengthen the global public health infrastructure and emergency response capabilities. It is in the interest of all states, particularly those in the developed countries, to give up the fortress mentality and develop effective strategies for international cooperation if the macabre tales of dreadful death and disease are to be avoided.
Notes 1 Ullman (1983, 133) defines a threat to national security as ‘an action or sequence of events that (1) threatens drastically and over a relatively brief span of time to degrade the quality of life for the inhabitants of a state, or (2) threatens significantly to narrow the range of policy choices available to the government of a state or to private, nongovernmental entities (persons, groups, corporations) within the state’. 2 The intervals between pandemics have ranged from 10 to 55 years over the last two centuries. With only three incidents per century, however, there is no statistical basis for a firm prediction (Weiner 2006). 3 This is what happened to the 1918 influenza after the western front was abandoned in World War I. In a little more than a year, the virus lost its virulence and evolved into an ordinary influenza (see Orent 2005). 4 Even the 1918 influenza, ‘the mother of all pandemics’, had a CFR of a bit more than 2.5 percent (Taubenberger and Morens 2006). The WHO data counted only lab-confirmed cases, and milder, non-fatal cases were likely not included. This is particularly a problem in many affected countries, where surveillance and healthcare facilities remain inadequate and only the very sickest cases go to the hospital. In Vietnam the reported mortality rate fell from 70 percent to 35 percent as more people learned about the disease (Weiner 2006). 5 This is suggested by research conducted by the University of Hong Kong (see Chan et al. 2005). For the distribution of mortality among different ages, see Crosby (2003, 24). 6 See also personal communication. 7 Renmin ribao, 14 May 2003, p. 11.
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Knobler, Stacey, Alison Mack, Adel Mahmoud, et al. (2005). The Threat of Pandemic Influenza: Are We Ready? Workshop summary prepared for the Forum on Microbial Threats and the Board on Global Health. National Academies Press, Washington DC. (September 2008). Lee Jong-wook (2005). ‘Speech on Human Pandemic Influenza.’ 12 October. World Health Organization, Geneva. <www.who.int/dg/lee/speeches/2005/avianinfluenza_singapore/ en> (September 2008). Lee Kuan Yew (2004). ‘New Viruses in Asia.’ Forbes, 19 April. Lewis, Maureen (2001). ‘The Economics of Epidemics.’ Georgetown Journal of International Affairs, vol. 2, no. 2, pp. 25–31. Malthus, Thomas Robert (1798). An Essay on the Principle of Population. (London: Macmillan and Co.). McNeill, William (1976). Plagues and Peoples. (New York: Anchor Press). McNeill, William (1977). Plagues and Peoples. Updated ed. (New York: Anchor Books). Meltzer, Martin I., Nancy J. Cox, and Keiji Fukuda (1999). ‘The Economic Effects of Pandemic Influena in the United States: Priorities for Intervention.’ Emerging Infectious Diseases, vol. 5, no. 5. <www.cdc.gov/ncidod/EID/vol5no5/meltzer.htm> (September 2008). Newcomb, James (2005). ‘Economic Risks Associated with an Influenza Pandemic.’ Written testimony before a hearing of the Committee on Foreign Relations, United States Senate, 9 November. Bio Economic Research Associates, Cambridge MA. <www.senate.gov/ ~foreign/testimony/2005/NewcombTestimony051109.pdf> (September 2008). Orent, Wendy (2005). ‘Battling an Epidemic of Fear.’ Los Angeles Times, 27 October. Osterholm, Michael T. (1996). ‘Emerging Infectious Diseases: A Real Public Health Crisis?’ Postgraduate Medicine, vol. 100, no. 5. 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). Paris, Roland (2001). ‘Human Security: Paradigm Shift or Hot Air?’ International Security, vol. 26, no. 2, pp. 87–102. Pirages, Dennis (1996). Microsecurity: Disease Organisms and Human Well-Being. Environmental Change and Security Project Report No. 2. Woodrow Wilson International Centre for Scholars, Washington DC. <www.wilsoncenter.org/topics/pubs/ACFA6.pdf> (September 2008). ‘Preparing for a Pandemic.’ (2005). Economist, 22 September, pp. 113–114. 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. Schelling, Thomas C. (1960). The Strategy of Conflict. (Cambridge MA: Harvard University Press). Simonsen, L., D.R. Olson, C. Viboud, et al. (2005). ‘Pandemic Influenza and Mortality: Past Evidence and Projections for the Future.’ In S.L. Knobler, A. Mack, A. Mahmoud, et al., eds., The Threat of Pandemic Influenza: Are We Ready? (Washington DC: National Academies Press). Stein, Rob (2003). ‘Americans Changing Habits Because of SARS, Poll Finds.’ Washington Post, 30 April, p. A12. 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).
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Part IV Accessing Affordable Medicines
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Chapter 8
Coming to Terms with Southern Africa’s HIV/AIDS Epidemic Hany Besada
In 2007, 33.2 million people worldwide were thought to be living with HIV/AIDS (UNAIDS and World Health Organization [WHO] 2007). Sub-Saharan Africa, with just over 11 percent of the world’s population, was home to 68 percent of all adults (22.5 million), 90 percent of all children living with the deadly virus, and 76 percent of the deaths. Meanwhile, more than 2.9 million children and adults died of AIDSrelated illnesses. Among young people aged 15 to 24 in the region, an estimated 61 percent of adults living with the disease in 2007 were women. Nowhere in Africa has the virus affected as many lives and disrupted more social and economic structures than in southern Africa. Indeed, the region remains the epicentre of the world’s devastating AIDS epidemic (see Table 8-1). HIV/AIDS affects approximately 20 percent of the population aged 15 to 49, in the region of southern Africa, comprising Swaziland, Lesotho, Malawi, Zambia, Zimbabwe, South Africa, Botswana, Namibia, and Mozambique. Nowhere in the world has the virus hit on the same scale, devastating so many lives, destroying local and national economies, undermining the limited healthcare services in place, and taking a heavy toll on the social structures in its path. At least 22.5 million Africans have died of AIDS since the virus was first identified in 1981 (‘AIDS in Africa’ 2008; World Bank 2008). Countries in the region continue to ponder how best to tackle this devastating disease. For years, their slow, inadequate and ad hoc responses to the onslaught of the disease profoundly exacerbated the already worsening situation. As Alexander de Waal (2006, 9) notes: AIDS kills millions every year, more than war and famine combined. It kills adults, devastating families and leaving orphans. But governments are not being overthrown. Indeed, with a few exceptions such as Botswana, African leaders’ responses lack urgency and scale. Governments find resources for many things, but AIDS programmes are rarely near the top of their list. There are straightforward reasons for this neglect. African electors are not demanding that their governments make AIDS a priority. Society is neither collapsing nor being transformed in revolutionary ways. African rulers, with a sound appreciation of how power functions, know that they will not be removed from office or even face political threats on account of AIDS.
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Current Situation in Southern Africa Unacceptable HIV prevalence rates exists in the vast majority of southern African states. In 2007, the region accounted for approximately 35 percent of all people living with the disease as well as roughly 32 percent of all new HIV infections and AIDS-related deaths (UNAIDS and WHO 2007). Countries such as Lesotho, Swaziland, Botswana, and Namibia have HIV prevalence rates exceeding 30 percent among pregnant mothers. Meanwhile, there is little indication that the prevalence of HIV is on the decline in these states. Swaziland In Swaziland, the epidemic has reached unprecedented proportions. According to the Central Statistical Office in Swaziland, approximately 26 percent of adults were infected in 2007. Data issued by the Ministry of Health indicate that the HIV prevalence rate among pregnant mothers has increased from 34 percent in 2000 to a record high of 43 percent in 2004 (UNAIDS 2005b). Those health ministry officials have indicated that there is little regional variation in the prevalence of HIV measured among women. In total, approximately 31 percent of all women were infected with the virus in 2007 (Swaziland Central Statistical Office 2008, xxvii). Table 8-1: Regional Comparison of HIV/AIDS, 2001 and 2007
Sub-Saharan Africa Middle East/North Africa South and Southeast Asia East Asia Latin America Eastern Europe and Central Asia Western and Central Europe North America
2007 2001 2007 2001 2007 2001 2007 2001 2007 2001 2007 2001 2007 2001 2007 2001
Adults and Adults and Adult Adult and children living children newly prevalence child deaths (%) with HIV infected with HIV due to AIDS 22.5 million 1.7 million 5.0% 1.6 million 20.9 million 2.2 million 5.8% 1.4 million 380 000 35 000 0.3% 25 000 300 000 41 000 0.3% 22 000 4.0 million 340 000 0.3% 270 000 3.5 million 450 000 0.3% 170 000 800 000 92 000 0.1% 32 000 420 000 77 000 0.1% 12 000 1.6 million 100 000 0.5% 58 000 1.3 million 130 000 0.4% 51 000 1.6 million 150 000 0.9% 55 000 630 000 230 000 0.4% 8000 760 000 31 000 0.3% 12 000 620 000 32 000 0.2% 10 000 1.3 million 46 000 0.6% 21 000 1.1 million 44 000 0.6% 21 000
Source: UNAIDS and World Health Organization (2007).
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Tragically, there is little indication that young adults and teenagers are engaging in safe sex practices. Women tend to be more affected than men. Considerable social pressure is also placed on women by their male partners not to insist on the use of condoms. Most African societies have patriarchal structures. In 2004, according to the Ministry of Health, up to 56 percent of pregnant mothers aged 25 to 29 years were diagnosed with the disease. It comes as no surprise that this country has had the world’s worst HIV epidemic since 2004 (United States Agency for International Development [USAID] 2004; Laurance 2008). Since 2004 it has had the largest percentage of HIV cases for the size of its population. In response to this national crisis, Swaziland’s government created the National Emergency Response Council on HIV/AIDS to come up with policy recommendations on how best to control the spread of the virus. However, the government’s capacity to respond effectively and comprehensively was undermined by depleting human and financial resources in its health as well as other sectors. The country is also faced with one of the many negative impacts of HIV/AIDS, namely the increasing number of orphans and other affected children who are left to fend for themselves without any social safety nets in the absence of their mothers, who are either dying or already dead. Botswana In Botswana, meanwhile, the situation is even more dire, although there are signs that the epidemic could be stabilising. The country has one of the world’s highest HIV prevalence rates: an estimated four out of every ten Botswanans carry the disease. The national HIV prevalence rate among pregnant mothers has remained between 35 percent and 37 percent since 2001. Among pregnant teenagers, the prevalence rate is stubbornly high at 18 percent in 2005. Because of insufficient funds, bureaucratic procedures as well as poor coordination and uncoordinated HIV/ AIDS policy among different departments, Botswana’s government has only recently begun to take serious steps to address the plight of thousands of Botswanans either directly infected or indirectly affected by the disease. The HIV infection level among pregnant women aged 25 to 49 was put at 32 percent in 2006, a slight improvement on the 2001 figures of 31 percent. This suggests that perhaps the epidemic is close to reaching its peak and the government could finally see gradual improvements in the fight to control the disease. Botswana’s National AIDS Council, with technical and financial support from the National AIDS Coordinating Agency (2003), has introduced a well-planned and coordinated multi-sectoral response, with HIV/AIDS as the focal interest of the national development plan. Currently, the National Strategic Plan on HIV/AIDS for 2003–2009 focusses on enlarging and improving the management of this multisectoral response and incorporating both the private and public sectors to assist government in fulfilling its pledge to stem the virus. In 2003, the government began introducing routine HIV testing to help identify the extent of the disease among the general population and to allow sufficient time for the introduction of antiretroviral therapy (ART) to HIV-positive patients.
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Zambia Next door from Botswana in Zambia, the situation is not any better. In 2007, more than 17 percent of Zambians were thought to be living with HIV/AIDS (United States President’s Emergency Plan for AIDS Relief [PEPFAR] 2008). There have been at least 800 000 cases of death as a result of AIDS-related illnesses and a further 710 000 children orphaned since 2006. It is projected that by 2015, AIDS will have taken the lives of at least 2.8 million Zambians, an 83 percent increase (Garbus 2003). By 2050 6.2 million Zambians are expected to have died from AIDS-related illnesses since the virus first appeared in the early 1980s (Garbus 2003). The disease is believed to have spread throughout the country, particularly in urban areas, hitting the most vulnerable groups hard, namely young women and girls. The HIV prevalence rate among antenatal women tested in major cities increased from 5 percent in 1985 to 27 percent in 1992, and has remained at that level ever since (UNAIDS 2004). In terms of the impact of the virus on the country’s macroeconomy, the International Labor Organization (ILO) projects that the country will experience a loss of up to 5.8 percent of its gross domestic product (GDP) per capita; of this percentage, there will be a loss of 1.7 percent to the capital/labour ratio, 1.0 percent to total factor productivity, and 3.1 percent to aggregate skills and knowledge of the workforce (cited in Garbus 2003). It also projects that Zambia will shed some 19.9 percent of its labour force by 2020, compared to what it would have been without HIV/AIDS. To deal with the effects of the disease in recent years, the Zambian government has sought the assistance of donor communities, the private sector, and state resources. It has received financial assistance over the years from a number or sources, including some US$42 million from the World Bank’s Multi-Country HIV/AIDS Program for Africa, a grant of US$18.5 million from the U.S. Agency for International Development (USAID) in 2002 to help support the national HIV/ AIDS programme, and an additional US$92 million in grants from the Global Fund to Fight AIDS, Tuberculosis, and Malaria in 2002 for HIV/AIDS prevention and mitigation (Garbus 2003).1 By 2003, new global initiatives designed to address the global HIV/AIDS pandemic earmarked millions of dollars for HIV/AIDS prevention and treatment programmes in Zambia. In 2007, USAID’s programme in the country provided the government with more than US$116 million, using PEPFAR funding.2 Meanwhile, the Zambian government restructured the National HIV/AIDS/ STD/TB Council, established in 2000, to serve as the single, high-level body responsible for technical and national leadership, effective coordination of all government and civil intervention, and strategic management. In 2002, Parliament passed the HIV/AIDS Act, which allowed the council to solicit funding. Since late 2003, the council has been shaped by a strategic framework designed to increase the distribution of ART to HIV-positive patients, de-stigmatise HIV/AIDS, promote community-based support to orphans, reduce high-risk behaviour (such as unprotected sex and multiple partners), promote behavioural change that includes abstinence and mutual fidelity, and introduce multi-sectoral responses to cope with the onslaught of the disease.
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Zimbabwe Only in Zimbabwe are there signs that the government is winning the battle to curtail the spread of the disease. In 2007, using the Epidemic Projection package and Spectrum software, the HIV prevalence rate was estimated to be around 15.6 percent, following a gradual decline from the 2001 figure of 26.5 percent (Zimbabwe National Monitoring and Evaluation Taskforce 2008, 4).3 Evidence from the government’s surveillance system shows that HIV prevalence among pregnant mothers, one of the most vulnerable groups in the country, has declined to 17.7 percent in 2006, down from 25.8 percent in 2004 (4). Studies from local nongovernmental organisations (NGOs) working with HIV-positive patients have categorically supported these findings. In Harare, HIV prevalence in women attending antenatal clinics dropped from 26 percent in 2002 to 18 percent in 2006 (10). This decline was also reflected in declines among men and women, aged 15 to 49, particularly in the rural areas (Zimbabwe Ministry of Health and Child Welfare 2007). Of particular importance is the fact that national statistics show a decline in HIV prevalence among young women aged 15 to 24 from 21 percent in 2000 to 13 percent over the same period. Other studies show similar developments among male factory workers in Harare and among antenatal women in other urban areas. Government officials contend that changes in sexual behaviour, consistent usage of condoms, and the successful National AIDS Coordination Programme (NACP) have contributed to these declines. According to national surveys, condom usage among sexually active partners has reached record levels of 83 percent among women and 86 percent among men (Mahomva 2004). There is further research indicating that Zimbabweans aged 15 to 49 are having fewer sexual partners on average (Mahomva 2004). Studies show that changes in sexual behaviour have led to mortality rates levelling off in some parts of the country, particularly in rural areas, leading to a decline in HIV prevalence rates (see UNAIDS 2005a; Mahomva et al. 2006; Mugurungi et al. 2007; Zimbabwe Ministry of Health and Child Welfare 2007). Meanwhile, the NACP was widely credited as advancing a sound policy to address the crisis. Officials are quick to point out that they were slow to respond to the crisis during the late 1980s when the first cases of AIDS were reported. During this period, discussion of HIV/AIDS was minimal and the country’s president, Robert Mugabe, rarely discussed the subject in public. It remained a taboo subject for many Zimbabweans until the mid 1990s. Even though the NACP was established in 1987, it was not until 1999 that the country’s first HIV and AIDS policy was announced. In 2000, the government began implementing that policy through the newly formed National AIDS Council, which replaced the outdated NACP. Since then, the government has introduced an AIDS levy on all tax payers to pay for the work of the council. Proponents of the NACP and the council credit them with helping to promote safe sex education and counselling for HIV-positive patients through state-sponsored media broadcasts on state television and radio and in public clinics and hospitals. Beginning in 2006, the government launched the National Behaviour Change Strategy for 2006 to 2010
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to raise awareness of the disease and intensify its efforts to address the root causes of risky behaviour. The strategy included provisions for reducing multiple sexual partners, condom usage, promoting faithfulness, and advocating for women’s rights. Also in 2006, the government in Harare scaled up its multi-sectoral response to the virus by launching the four-year Zimbabwe National and HIV/AIDS Strategic Plan. The plan builds on the lessons and recommendations from the National AIDS Policy of 1999 as well as the National HIV/AIDS Framework (2000–04), which was credited with the recent successes through a well-planned advocacy and educational policy. Studies show that the declines in HIV prevalence rate in Zimbabwe are largely due to behavioural changes among sexually active adults (Hallett et al. 2006). Studies indicate that in the eastern part of the country more men and women are increasingly avoiding high-risk practices, such as sex with non-regular partners. Moreover, more women insist on consistent use of condoms (Gregson et al. 2006). In recent years, the country has been able to fund its HIV/AIDS programmes through various funding mechanisms. As a signatory to the 1998 Abuja Declaration to roll back malaria, Mugabe’s regime has committed a minimum 15 percent of the government’s budget to the national healthcare sector. The government, through taxes and the National AIDS Trust Fund, earmarked a further 3 percent levy collected and administered by the Ministry of Finance from all taxable income in order to fund HIV/AIDS-related initiatives (Zimbabwe National Monitoring and Evaluation Taskforce 2008, 5–6). This represented roughly 13.7 percent of total government spending on the health sector in 2007. Contributing to Harare’s ambitious HIV/ AIDS programmes, the international community further provided US$41.93 million in 2006 and US$64.30 million the previous year. Meanwhile the United Nations contributed US$24.14 million and $10.43 million in 2006 and 2005 respectively. Zimbabwe also received additional funding for the period from the Global Fund in the amount of US$60 million. Consequently, the availability of medical care provided by the government and NGOs to HIV-positive patients has increased in recent years due to efforts to promote access to treatment, although it still does not meet the needs of all who desperately need treatment. Voluntary counselling and testing programmes have been expanded over the past five years and are currently administered either free of charge or at a nominal fee. In 2006, one month’s ART, without additional tests, cost approximately Z$500 000 (US$5) per month in the public sector and between Z$2 million and Z$6 million (US$20–US$60) per month in the private sector (Human Rights Watch 2006). Meanwhile, approximately 200 facilities across the country have begun providing preventing mother-to-child transmission (PMTCT) services. However, this is not to say that the disease has been firmly put in check in Zimbabwe. The country continues to record one of the highest HIV prevalence rates in the world. According to 2005 National Estimates from the Ministry of Health and Child Welfare, 115 000 people living with HIV/AIDS are children aged 15 and under. During the same year, approximately 162 000 Zimbabweans were living with the virus and a further 170 000 died from AIDS-related illnesses, or more than 3000 a week (Human Rights Watch 2006, 17). Recent statistics show that one in
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five pregnant mothers continue to test HIV positive, one of the highest levels in the world. Much can be done to bolster the government’s prevention programme to penetrate more remote rural areas across the country (Human Rights Watch 2005). At the same time, there has been increasing criticism regarding the efficiency at which ART is being provided. In 2006, the country announced a rapid increase in the provision of ART (with the goal of having more than 300 000 people on ART by 2010). But only about 230 000 out of the 350 000 Zimbabweans in need of ART are currently being treated (Human Rights Watch 2006).
Case Study: South Africa South Africa is a land of sharp contrasts and intractable divisions that plague its much-applauded political transformation since the end of apartheid in 1994. Two very different worlds have emerged within the country—one with affluent firstworld standards applying mainly to white South Africans (9.6 percent of the total population) and the other, an impoverished world, populated by the majority of its black population who make up 79 percent of the total population (Statistics South Africa 2003). Indeed the country has a two-tiered economy. At one level, its largely wealthy white population has long continued to reap the benefits of a competitive and robust economy. Assessed on its own, white South Africa would have been ranked 24th in the world in 1994, competitive with Hong Kong, Spain, and Greece, according to the 1994 Human Development Index (United Nations Development Programme [UNDP] 1994). At the other level of the economic divide, extreme poverty continues to engulf the large majority of non-white citizens. On its own, black South Africa would have been ranked 123rd. Put in other terms, 20 percent of white South Africans earned 20 times more than their poorest black counterparts (Besada 2007). Scholars such as Alan Whiteside and Clem Sunter (2000) have argued that this income disparity and poverty, which continue to afflict the bulk of the population, have created a fertile ground for the spread of the HIV/AIDS. In turn, the epidemic compounds and even deepens the crisis situation by negatively affecting labour trends, population growth, the entire healthcare system, and more. In short, poverty increases the likelihood of contracting HIV/AIDS and HIV/AIDS worsens the conditions associated with poverty. According to Whiteside and Sunter (2000), South African society is both particularly susceptible to the spread of HIV and particularly vulnerable to its impact, because of a downward spiral of existing social, economic, and human deprivations. They hypothesise that the rate and spread of infection in any given country depend on two variables: the degree of social cohesion and the overall level of wealth. If this theory is applied to South Africa—a country with low levels of social cohesion and relatively high and disparate incomes—then the rapidly spreading HIV/AIDS epidemic in South Africa is a telling case. Whiteside and Sunter conclude that ‘the country will be waging an uncivil war against an invisible enemy more ruthless than any human adversary’.
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To add to such assertions about the link between poverty and inequality and the spread of HIV/AIDS in South Africa, Mark Hunter (2007) has outlined three interlinked dynamics critical to understanding the scale of the HIV/AIDS pandemic in South Africa: rising unemployment and social inequalities that leave groups extremely vulnerable; greatly reduced marital rates and the increase of one-person households; and rising levels of women’s migration, especially movements between rural areas and urban areas. As a window into these changes, Hunter pays particular attention to the country’s burgeoning informal settlements—where HIV/AIDS rates are reported to be twice the national average—and to connections between poverty and the exchange of money for sex. Hunter (2007) further argues that rising unemployment and sharpening inequalities have reconstituted sexual relations and networks in decisive ways. When it comes to dealing with the epidemic, he wants to see more attention given to recent politicaleconomic shifts. In South Africa, although democratic transformation ended explicit racial forms of domination, the market-based policies favoured by the post-apartheid state have created new social divisions that help to fuel the HIV/AIDS pandemic. Hunter draws on extensive archival and ethnographic research and field work that reveal dramatic changes in relationships over the last generation: the plummeting of marital rates such that less than 30 percent of adult Africans are currently in wedlock; the rapid reduction in the size of households, seen most vividly in the rise of one-person households in informal settlements; the sharp increase in women’s movement that challenges the overwhelming prominence given to male migrancy as a conduit for HIV infection; and the emergence of the ‘materiality of everyday sex’ that can fuel multiple-partnered relationships but where ‘gift exchanges’ are not simply instrumental but characterised by an exchange of obligations that might include love and affection as well as money and sex. Whether or not these assertions merit some truth, the HIV/AIDS epidemic in South Africa is dire (see Table 8-2). In 2006, an estimated 350 000 persons died of AIDS in South Africa, or 950 per day (Dorrington et al. 2006b). Meanwhile, the HIV-prevalence rate for adults aged 15 to 49 was estimated at 18.34 percent for 2006 (South Africa Department of Health 2007). In 2006, an estimated Table 8-2: HIV/AIDS Indicators for South Africa Prevalence rate in people aged 15–49 years, 2006 Total people living with HIV/AIDS, 2006 Total children (0–14 years) living with HIV/AIDS, 2006 Estimated HIV prevalence among antenatal clinic attendees, 2006 Reported AIDS-related deaths, 2005 Number of people estimated receiving antiretroviral treatment, June 2005 Number of people estimated needing antiretroviral treatment, June 2005 Estimated HIV prevalence among antenatal clinic attendees, 2006
18.34% 5.41 million 257 000 29.1% 591 213 97 000–138 000 866 000 29.1%
Source: South Africa Department of Health (2007); National HIV and AIDS and TB Unit (South Africa) (2006); Khomanani (2008); UNAIDS (2008).
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5.41 million people in the country were HIV positive while 1000 new infections occurred daily (Wines 2006). It is predicted that the number will increase to 6 million by 2015, by which time approximately 5.4 million people will have died of the disease (Dorrington et al. 2006a). It is widely believed that almost half of all deaths in the country and an astonishing 71 percent of deaths among HIV-positive people aged between 15 and 49 are caused by AIDS (21). The situation is so severe in parts of the country that cemeteries are running out of space due to the number of deaths (Wines 2004). A poll in 2004 found that South Africans spent on average more time at funerals than they did shopping or at barbershops. It also found that in any given month twice as many South Africans could be found at a funeral than at a wedding (South African Advertising Research Foundation 2004). Today, average life expectancy has decreased to 54 years, down from an estimated 64 years prior to a decade ago. More than half of the country’s 15 year olds will not live long past the age of 60 (Dorrington et al. 2006a, ii). Hospitals can barely cope with the dramatic in-flow of HIV-positive patients seeking medical care. In 2006, HIV-positive patients accounted for more than 60 percent of medical expenditure in the country’s public hospitals (Palitza 2006). According to Statistics South Africa, between 1997 and 2004 adult mortality among people aged 15 to 64 increased, largely due to AIDS-related deaths (Lehohla 2006). Over the past decade young adults, particularly women, have been especially hard hit by the disease. From 1997 to 2004 the death rate for women aged 20 to 39 more than tripled and doubled for men aged 30 to 44. UNAIDS (2008) estimates that approximately 58 percent of HIV-positive people in the country are women. Looking at all age groups, the relevant government department has recorded an increasing number of deaths due to HIV/AIDS from 1997 to 2005. Pali Lehohla (2006), head of Statistics South Africa, said ‘a large part of this increase can be attributed to HIV, where death rates have a distinctive age pattern in which there is an increase to a given age and then a rapid decline at older ages’. Even more disturbing is the fact that HIV/AIDS activists around the country and international health organisations working with NGOs have long argued that many more deaths are believed to have been caused by HIV/AIDS, even though they are often recorded as being due to another cause. Both UNAIDS and Statistics South Africa have noted that the percentage of HIV-positive pregnant women at public antenatal clinics increased from 1 percent in 1990 to 17 percent in 1997 and 30 percent by 2004 (Knight 2006). According to the South African Department of Health (2007), the HIV-prevalence rate among pregnant women was estimated at 29 percent in 2006. Taking into account this factor among many others to assess the projected outlook for the disease in the country, both UNAIDS and Statistics South Africa have reiterated a point that many had long believed was true: HIV/AIDS deaths will likely continue to increase in South Africa for the foreseeable future. The South African government has come under fire both domestically from HIV/AIDS activists and NGOs and from international health organisations and governments for its slow response to the pandemic, particularly for its reluctance to provide ART for a number of years. As president, Thabo Mbeki and his minister of
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health, Manto Tshabalala-Msimang, authorised the delivery of antiretroviral drugs to public hospitals only in 2004, years behind many of its neighbours, including Zambia and Botswana. The sacking of the deputy minister of health by Mbeki in August 2007 was a further indication of what is tragically going wrong with South Africa’s lacklustre and often disappointing approach to tackling the HIV/AIDS pandemic. Critics contend that the deputy minister was punished for her outspoken criticism of the state’s controversial HIV/AIDS policy regarding ART and the unorthodox attitudes toward AIDS among certain government officials, including the president. Mbeki and Tshabalala-Msimang have been criticised for questioning the link between the HIV virus and AIDS and the extent to which the disease has spread in South Africa. On a number of occasions, they argued that the championing of ART by pharmaceutical companies was a ploy to maximise profits, while the safety and effectiveness of these drugs were questionable. Mbeki emphasised prevention as the main driver behind the government’s AIDS policy. Meanwhile, Tshabalala-Msimang was known as ‘Dr. Beetroot’ for her suggestion that HIV patients eat beetroot and garlic as substitutes to ART, the efficacy of which she questioned on more than one occasion. At the 2006 International AIDS Conference in Toronto, food products such as beetroot and garlic were displayed prominently on the country’s exhibition stand. Widespread criticism by the event managers and reporters prompted the minister of health to add ART to the display. Domestically, the Treatment Action Campaign, a South African organisation founded by the HIV-positive activist Zackie Achmat in 1998 to advocate for the rights of HIV-positive people in the country, condemned the government for its slow response. Achmat publicised the situation by refusing to take ART himself until it was distributed to all HIV-positive patients around the country. On the international front, Stephen Lewis (2006), in one of his last speeches as UN Special Envoy for HIV/AIDS in Africa, said that: South Africa is the unkindest cut of all. It is the only country in Africa … whose government is still obtuse, dilatory and negligent about rolling out treatment. It is the only country in Africa whose government continues to propound theories more worthy of a lunatic fringe than of a concerned and compassionate state … I’m of the opinion that they can never achieve redemption.
The government’s decision to administer ART to HIV patients was made possible following a court battle in which pharmaceutical companies such as GlaxoSmithKline agreed to allow low-cost generic versions of their drugs to be produced in the country. This allowed South Africa to become one of the first African states to produce its own low-cost HIV/AIDS drugs. Although the decision to administer ART was widely applauded both domestically and internationally, many have since expressed their disappointment about the slow pace at which these drugs have been made available to HIV-positive patients and the low number of people who actually received them as part of the government’s AIDS programme. Although the government’s 2003 plan aimed to put more than 381 177 HIV-positive people on a generic ART cocktail by
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2005 out of a population of more than 866 000 persons needing it immediately, only 85 000 people received treatment in the public health sector by the end of that year (South Africa 2005; Pembrey 2008). By 2006, the World Health Organization (WHO) stated that approximately 67 percent of South Africans who needed ART had not received it and should only expect to receive it in the medium to long term (see WHO, UNAIDS, and UNICEFF 2007; Pembrey 2008). The South African government has been equally criticised for its slow response in making the drug nevirapine available to HIV-positive pregnant women to help prevent the transmission of the virus to their babies. In 2000, the South African Department of Health announced plans to establish two sites for PMTCT in each of the nine provinces of the South Africa. That, however, did not solve the issue of making antiretroviral drugs available to HIV-positive pregnant women. Lawsuits were subsequently filed against the government in 2001 at South Africa’s constitutional court, which called into question the safety of the drugs and their effectiveness, in spite of the consensus medical opinion. The following year the constitutional court ordered the minister of health to distribute nevirapine to HIV-positive pregnant women. Despite government claims that the drug had been made available throughout the country, it dragged its feet when it came to introducing dual therapy—where HIV-positive mothers are given the required dosages of zidovudine (AZT) as well as nevirapine. In affluent opposition stronghold communities such as in the Western Cape Province, where dual therapy had been administered since 2004, the rate of mother-to-child transmission had been reduced by more than 8 percent, compared to areas such as the Limpopo Province, where the rate is over 22 percent in the absence of ART. In 2006, an estimated 64 000 babies were diagnosed with the disease in the country through mother-tochild transmission (38 000 infected at birth and 26 000 infected through breast milk) (Dorrington et al. 2006a, 27). The South African government’s slow response to administering ART has often been blamed by AIDS activists in South Africa for the subsequent infant mortality and the continual rise in HIV/AIDS-related deaths. However, researchers point out that this is only part of a wider problem facing HIV-positive South Africans. The prevalence of misinformation about the disease has not only curtailed efforts to increase access to ART, but it has also been blamed for creating a climate of confusion has enabled prejudice toward HIV-positive people to thrive despite efforts by the government’s AIDS awareness programmes. It is often said that HIV is a ‘poor person’s’ disease, affecting mostly the most marginalised segment of society. Although there is a correlation between high HIV prevalence and extreme poverty, unemployment, and illiteracy, HIV is prevalent in all racial and socioeconomic groups. Although HIV-positive people from largely affluent white neighbourhoods began publicly announcing their status as early as 1998, the stigmatisation surrounding the disease has continued to dominate largely black townships such as Soweto and Alexandra. In October 1998, as deputy president, Mbeki issued the Declaration on Partnership Against AIDS (South Africa 1998), which called for an
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end to discrimination against people living with HIV. However, it became clear that it would take a long time to deal effectively with the stigma and discrimination that many HIV-positive South Africans face on a daily basis. Two months following the announcement, Gugu Dlamini, an AIDS activist in Durban, was beaten to death by her neighbours on World AIDS Day after she declared her HIV status. Indeed, as many studies have shown, an HIV-positive diagnosis can negatively affect the housing and employment opportunities for many people. A study by the Henry Kaiser Foundation found that only one third of respondents who had revealed their HIV-positive status met with a positive response in their communities (Steinberg et al. 2002). One in ten said they had met with outright hostility and rejection. In an effort to break the taboo, in 2005 Nelson Mandela publicly announced the cause of his son’s death—‘Some time now, I have been saying: “Let us give publicity to HIV/ Aids. Let us not hide it.” Because the only way in making it appear like a normal illness’ (Kalideen and Malefane 2005). However, the dismissal of Tshabalala-Msimang and the appointment of Barbara Hogan as South Africa’s new health minister by the country’s interim president Kgalema Motlanthe in September 2008 suggest a shift in the government’s AIDS policy. Hogan has a reputation for being a strong advocate of ART rather than nutrition as a means of treating HIV. There are also a few hopeful signs as businesses have begun to heed the calls of NGOs and civil society groups working with HIVpositive people to tackle the onslaught. With rising absenteeism, sickness, and death and decreased productivity among their workforce, businesses have begun initiating educational programmes and workplace awareness to help prevent the spread of the disease among their employees. With increased infection rates among their employees as HIV spreads among wider populations, companies’ profits decline. Consequently, larger firms such as Anglo American have realised that it is disadvantageous to wait for employees to die off and then replenish the workforce by hiring and training replacements. Rather, many companies have launched HIV/ AIDS programmes of their own that provide ART to employees who need medication and provided incentives for others to determine their HIV status. Anglo American had 2500 employees on ART by the end of 2004 and reported that approximately 94 percent were able to carry out their normal duties (AIDS Foundation South Africa 2005). It cost the company approximately R16 000 (US$2100) per year to keep an employee on treatment, a low price to pay given the tremendous costs to keep up an unproductive and dying workforce and to hire and train new replacements (AIDS Foundation South Africa 2005). The growth in the number of HIV-positive patients, albeit lower than expected, reflects a change in government policy. An AIDS programme that stresses a healthy diet and a prevention strategy is insufficient over the long haul in stemming the number of AIDS-related deaths. The roll-out of ART in November 2003 constituted an important component of the government’s Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South Africa (South Africa 2003). Although highly ambitious, the plan calls for a comprehensive distribution of ART to all HIV-positive South Africans by 2009. It includes the promotion of
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treatment of opportunistic infections, good nutrition, prevention, counselling, traditional medicine, and healthy lifestyles. Part of the South African government’s HIV/AIDS policy is to strengthen the national health system to accommodate the medical needs of HIV-positive patients. Currently, there is at least one service point for HIV/AIDS-related treatment and counselling in each of the 53 health districts across the country and a further 250 state laboratories are certified to provide support for the programme. The relevant government department has also worked hard to attract and retain nurses, doctors, and pharmacists, who are often lured to better working conditions and better pay in the West. By 2006, the government had helped to recruit more than 1060 doctors specifically to support the national HIV/AIDS policy. A further 9000 had been trained in the treatment, care, and management of HIV/AIDS (Knight 2006). The national HIV/AIDS policy also emphasises prevention. PMTCT includes providing baby formula, counselling, and nevirapine in public clinics and hospitals. By 2004, it was estimated that up to 78.7 percent of HIV-positive mothers received nevirapine in public hospitals and clinics (South Africa 2006). The government forecasts that more HIV-positive mothers will receive nevirapine over the next five years as the number of HIV-positive pregnant women at public antenatal clinics increases. As part of the government’s prevention strategy, more than 1.3 million condoms for women and another 386 million for men were distributed free of charge in 2006. The government has involved the media to publicise the HIV/AIDS epidemic and its prevention efforts. The Khomanani, the state’s flagship prevention campaign, was introduced to promote sexually responsible behaviour and reduce the number of new HIV infections, particularly among young adults and teenagers, as well as to stimulate action for support to vulnerable victims of the disease such as orphans and single mothers. As part of its holistic approach, apart from administering ART and promoting prevention strategies, the government has championed the need for a good diet among HIV-positive patients to help fight off infections while taking AIDSappropriate drugs. Since April 2004, nutrient supplements have been supplied to 480 000 qualifying tuberculosis (TB) and HIV-positive patients ‘as a complement to the appropriate forms of treatment’ (South Africa 2008). By 2006, the South African government’s expenditure on HIV/AIDS had reached the level of R3 billion (US$388 million), up from R30 million (US$3.9 million) in 1994 (Knight 2006). The government has warned that for the programme to be expanded to distribute more ART and nevirapine, as well as to sustain its public awareness campaign, more funding would be needed, particularly from the international community and business. Even though the cost of AIDS drugs has plummeted in recent years as a result of the manufacturing of generic versions, HIV-positive patients will need not only these drugs but also continual testing and counselling for the rest of their lives. This is a high price to pay for South Africa and many other southern African states. The costs of treating HIV-positive patients will increase as more and more people are being treated (see Table 8-3).
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Implications for a Global Health Governance Framework In light of the above-mentioned national, regional, and global responses to the onslaught of the HIV/AIDS epidemic in the region, it is imperative to identify how to integrate them within the global health governance framework to help achieve the desired goal: the halt and eventual eradication of the disease. This could perhaps best be contextualised and framed within a well-planned, effective, and sustainable system responsiveness and transformation process. In order to do this, challenges, responses, and innovative tools are explored here in some detail. Challenges Tracing the processes and pathways of a physical health challenge and its impact on those at the epicentre of the world’s devastating HIV/AIDS epidemic requires an in-depth understanding of the magnitude of the problem. Sub-Saharan Africa encompasses 68 percent (approximately 22.5 million) of all people living with the deadly virus. Moreover, the devastating HIV/AIDS disease affects roughly 20 percent of the population between the ages of 15 and 49 in a large number of southern African states. Humans remain the source of this attrition disease. However, controlling transmission of the deadly disease is possible through changes in sexual behaviour, consistent usage of condoms, and government-funded educational and counselling programmes that address HIV/AIDS issues openly. This has been successfully demonstrated in Zimbabwe where the availability of medical care and treatment Table 8-3: The Impact of HIV/AIDS on HIV-Related Health Services in Southern Africa (In percent of gross domestic product) Palliative care Clinical and prevention treatment of of opportunistic opportunistic infections infections 2000 2010 2000 2010 Botswana 0.1 0.1 0.2 0.3 Lesotho 0.1 0.3 0.5 1.0 Malawi 0.4 0.5 1.5 2.0 Mozambique 0.3 0.5 1.1 1.8 Namibia 0.1 0.1 0.4 0.6 South Africa 0.0 0.1 0.2 0.3 Swaziland 0.1 0.2 0.4 0.8 Zambia 0.2 0.2 0.8 0.9 Zimbabwe 0.2 0.3 0.8 1.1 Source: Haacker (2001).
Cost of highly active antiretroviral therapy 2000 2010 0.2 0.5 0.7 2.0 2.4 4.0 1.7 3.6 0.4 0.9 0.2 0.5 0.5 1.1 1.3 1.7 1.1 2.2
Total HIV-related health services, for assumed rates of coverage 2000 2010 0.5 0.9 1.3 3.2 4.3 6.5 3.0 5.9 1.7 7.5 0.3 0.9 1.0 2.1 2.3 2.8 2.1 3.5
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centres promoting safe sex education and counselling for HIV has helped patients dilute the stigma over a taboo subject. Erratic sexual activity and drug addictions make abstinence and condom use difficult to implement. However, the persistence of HIV/AIDS in South Africa demonstrates how suspicions of former imperial powers, misinformation, sheer ignorance, and complacency can exacerbate the impact of a disease by making it more difficult to disseminate vaccines and medicine. Mbeki and his minister of health on numerous occasions publicly claimed that ART was a ploy by pharmaceutical companies to maximise profits, stating that the drugs’ safety and efficacy were questionable. This needless rhetoric was accompanied by unsubstantiated claims that a diet of beetroot and garlic would suffice as a substitute for antiretroviral drugs. There is a need both for southern African states and the international community to reassess the concept of security, especially the human element, in the context of HIV, international politics, and development. The HIV/AIDS epidemic and the challenges that it poses to governments in the region, as well as the accompanying global responses, must take into account the consequences for international security. The HIV/AIDS epidemic should be treated with the same levels of engagement and intensity that accompany other traditional security threats, particularly the global response to international terrorism following the attacks of September 11. As Pieter Fourie and Martin Schönteich (2001) argue, HIV/AIDS overwhelms health services, shortens lives, destabilises governments, and disrupts societies, sometimes to the extent that major conflict ensues. They predict that in South Africa, the rapid spread of HIV/AIDS will likely result in a severe shortage of skills and human resources needed for effective government. Consequently, political instability may result in complex humanitarian emergencies and crime, neither of which can be addressed without effective government. Fourie (2006) assesses the social and political impact of HIV/AIDS in the country using human security as a lens through which to determine the causes and effects of the unfolding disaster. He focusses specifically on the implications of HIV/AIDS on food, populations, security, and the government’s ability to provide essential services. Fourie concludes that unless public policy makers address the structural causes of the AIDS epidemic (race relations, sexual violence, and cultural factors), the country will continue to suffer the ravages of the epidemic. Response There has been tremendous interest in support for initiatives that combat HIV/AIDS in southern Africa from various governments, local and global NGOs, international health organisations, civil society, and the private sector. However, in some instances this interest has not translated into sufficient tangible monetary support. In Swaziland, the government’s capacity to respond effectively to the HIV/AIDS crisis has waned due to depleted human and financial resources both in health and other sectors. On the other hand, the response to Zambia’s plight has been financial resources to the tune of US$42 million from the World Bank’s Multi-Country HIV/
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AIDS Program for Africa, US$18.5 million from USAID, and US$92 million from the Global Fund for HIV/AIDS prevention and mitigation. This influx of funding has been followed by government initiatives to restructure its National AIDS Council and the passing of the HIV/AIDS Act. In Botswana, the National AIDS Council has offered its technical and financial support for a well-coordinated multi-sectoral response for afflicted populations through government-assisted programmes to stem the spread of the virus. Although slow to respond to the crisis, Zimbabwe has taken steps to address many of the daunting challenges surrounding HIV/AIDS. The government’s national AIDS programme advanced sound policy to address the crisis and sought cooperation from print and broadcast media to channels messages promoting safe sex education and counselling. South Africa’s response to the HIV/AIDS crisis has been rather lax and irritating. After heavy criticism and ridicule from both domestic and international players for its slow reaction to the pandemic and campaigns of misinformation, the government eventually began to heed calls for change. It is now collaborating with NGOs and civil society groups to help curb the increasing prevalence rates. With Barbara Hogan appointed minister of health and the resgination of Thabo Mbeki as president, the government’s national HIV/AIDS policy is expected to emphasise the importance of ART, prevention, and health education for HIV-positive patients. Innovation The importance of government awareness programmes cannot be underestimated. They empower women from traditionally patriarchal societies to be better informed. A women’s low social status within such societies has a direct correlation to the contraction of HIV/AIDS. Educational programmes and counselling services on preventive measures against HIV/AIDS are a highly effective means of reducing prevalence rates. In addition, the use of print and broadcast media is useful in raising awareness of the HIV/AIDS epidemic and its prevention effort. Publicity has also proven successful in seeking support for vulnerable victims of the disease and helps de-stigmatise those afflicted by it. Other innovative strategies that bode well for controlling the spread of the disease include Zimbabwe’s implementation of a comprehensive participatory approach that included all sectors of society agreeing on policy. Inclusive prevention and treatment programmes are accompanied by what the government introduced as an AIDS tax to pay for the work done by the National AIDS Council. After a long court battle with pharmaceutical companies, the South African government allowed an innovative achievement for specific companies to produce and sell low-cost generic versions of their drugs. This made South Africa the first African state to produce its own low-cost HIV/AIDS drugs. Therefore, this low cost increased the potential accessibility of the drugs to a broader segment of the population.
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Systemic Responsiveness and Transformation Regarding the responsiveness of innovative practices against HIV/AIDS in southern Africa, two cases stand out as defining polar opposites in terms of reaction time. Zimbabwe and South Africa handled their respective crises very differently early on. In the latter’s case, the challenge was not taken seriously, leading to high prevalence rates and complacency that left thousands dead. In Zimbabwe’s case, the government advanced sound policy to try to curtail the crisis relatively quicker than South Africa. In both cases, the reasoning for the implementation of innovations depended on the country’s respective analysis and evaluation of the current situation. For example, South Africa’s reliance on the traditional beetroot and garlic concoction versus the ART to help curb HIV/AIDS prevalence rates over many years did not help control the pandemic. This resulted in stagnant and inappropriate policy standards that led both to the reduction of South Africa’s population and to damage to its reputation. On the other hand, Zimbabwe’s timely and appropriate actions taken in the face of mounting prevalence rates comparatively early allowed for changes in sexual behaviour and the successful implementation of the government national AIDS programme, which contributed to a decline of HIV prevalence rates. The effectiveness of these innovative schemes however, did not always have a direct impact on prevalence rates. Regardless of the opportunity to lower rates, the discounted price of the ART did not render the treatment accessible to all, leaving only one sixth of those infected in South Africa able to receive the drugs. Despite Zimbabwe’s successes, the country continues to record one of highest HIV prevalence rates among those aged 15 to 49. There are also problems with efficiency, as ART does not reach other more rural communities that are also affected by the disease.
Lessons Learned and Policy Recommendations Ten major lessons and policy recommendations flow from this analysis. First, the HIV/AIDS epidemic is worse in southern Africa than anywhere else in the world. In eight of the nine countries in the region, adult prevalence rates are the highest in Africa. Even though there are projections that indicate that HIV prevalence rates are levelling off in some age groups in several of these countries, Zimbabwe appears to have achieved the most success in stemming the tide of the disease among almost all age groups and pregnant women. Second, the low status of women in the traditional patriarchal societies in many of these countries has led to many contracting HIV/AIDS. Women who are brought up in such villages, which is the majority of women, are taught not to question the reluctance of many men to use condoms. This is increasingly changing as government awareness programmes highlight the importance of condoms as a highly effective means of preventing HIV. Condoms are becoming more available even in remote areas of the region.
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Third, as the prevalence of HIV continues to rise in a number of southern African countries, more and more lives will be lost to the virus over the next decade. It is now projected that more than 16 million people will be infected by 2015, which, according to UNAIDS, is up from the previous estimate of 14.5 million (UNAIDS 2008). As more people become infected, it is widely expected that the number of cases that develop into AIDS in the region each year will ultimately rise. UNAIDS expects that there will be up to 1.6 million new cases annually in South Africa by 2015, which is up from 0.8 million in 2000. This will take a heavy toll on economic and social structures, already severely weakened by, among many other factors, the onslaught of the disease. Fourth, there is consensus among NGOs and international health organisations that Zimbabwe’s response to the AIDS crisis has been relatively effective, given the country’s huge economic and other social problems. With HIV prevalence in Zimbabwe declining—albeit slowly—among a large number of age groups as a result of the acceleration of prevention and treatment programmes in recent years, the country seems to be on the path to controlling the spread of the disease, at least in the short term. This was made possible by the implementation of a comprehensive national policy on HIV/AIDS. This policy was characterised by a participatory approach that provided ample scope for involvement by all sectors of society and resulted in a consensus policy adopted and implemented by all stakeholders, including NGOs, business, community leaders, and government. However, it remains questionable whether the government can sustain all the progress that was made given the economic meltdown and other difficulties that the country is now facing. Fifth, South Africa has more people infected with HIV/AIDS than any other country on earth. It continues to face acute problems in responding effectively to the epidemic that has affected the lives of millions of its people. For a long time, the government resisted efforts to provide ART to the millions of HIV-positive people who desperately needed such therapy. Meanwhile ambiguous statements made by Thabo Mbeki when he was president alleging that the connection between HIV and AIDS is poor, and calls by his minister of health Manto Tshabalala-Msimang for beetroot and garlic as substitutes to AIDS drugs, complicated and delayed the government’s response and plan of action to tackle the disease. Nonetheless, there is room for optimism due to the intense criticism the government had to face from AIDS activists in the country and international health organisations, as well as the subsequent appointment of Barbara Hogan as health minister. This pressure resulted in the expectation that increased treatment and counselling services will be made available to most HIV-positive South Africans over the coming years. Sixth, there are increased funding initiatives by donor communities. At the 2008 Hokkaido Toyako Summit of the G8 leaders renewed their 2007 pledge to allocate US$60 billion—of which no less than US$30 billion would come from the U.S. and PEPFAR—to fight TB, HIV/AIDS, and malaria in Africa (G8 2007, 2008; White House 2007). In addition to PEPFAR, designed to expand and intensify the U.S. government’s HIV/AIDS support to national prevention and treatment programmes in southern Africa in particular, there need to be strong communication
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networks to absorb and utilise this aid effectively in the short and medium terms. Donor communities should be encouraged to work not only with local and national governmental bodies in these countries, but also with the many local networks and organisations that work at ground level to deliver HIV/AIDS-related programmes. Governments and, increasingly more importantly, NGOs and religious and community-based organisations have important links with local communities. These allow them to play a vital role in any successful HIV/AIDS prevention and treatment programme, due to their credibility among local communities. Seventh, despite the progress that has been made on the ground to provide affordable treatment to HIV-positive people in the region in recent years, the majority of carriers of the disease are still not receiving treatment. According to the World Bank (2008), only one in six (17 percent) of all HIV-positive patients are receiving ART. In addition, government campaigns designed to prevent new infections from taking place, including campaigns organised to support safe sex education, are in many instances ineffective or undermined by technical, operational, or funding deficiencies. Any international or indigenous effort designed to stem the tide of the virus in the region needs to take such realities into consideration and look at ways to boost local capacity and resources. Eighth, although increasing funding from donor communities is always welcomed and needed to support the many initiatives in place to tackle the HIV/AIDS epidemic in southern Africa, more consideration ought to be given to the brain drain of medical doctors and nurses working in the health service sector in the region who are lured to greener pastures in the West. Attracted by higher salaries, the prospects of a better life, and better working conditions, large numbers of medical staff have left southern Africa to work and settle permanently in the West. Strategies should be put in place with the assistance of western governments to limit the intake of medical practitioners from the region and offer incentives, such as allowances for working in rural areas or for having scarce skills in order to help retain these resources to support their governments’ initiatives to prolong the lives of HIV-positive patients and prevent new infections from taking place. Ninth, southern African states should be encouraged to tackle the all important issue of reducing the stigma and discrimination faced by many HIV-positive people in the region. Sadly, these attitudes hinder effective responses to efforts at tackling HIV/AIDS over the long term. Often, many people engaging in high-risk activities such as engaging in unprotected sex and sharing injection needles hesitate to be tested for HIV and to seek treatment for fear of backlash from their communities, families, and co-workers. Governments and NGOs working in the region should focus more on dispelling fallacies regarding the disease and emphasise the need for periodic testing as a way to raise awareness and understanding among the general public. Tenth, safe male circumcision should be encouraged by the public health sector in the region, following recent studies by the WHO and UNAIDS. These indicate that this practice could help reduce the transmission of HIV via heterosexual sex. However, male circumcision on its own is not enough. It must be accompanied by safe sex practices.
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Conclusion Notwithstanding domestic and international efforts to tackle the HIV/AIDS epidemic in southern Africa, the region most affected by the disease over the past decade, there is little indication that the battle to eradicate or even contain the disease is being won. Millions more individuals in southern Africa will continue to be affected, either through the loss of their loved ones or by succumbing to the disease themselves, before these countries will begin to harvest the fruit from their national HIV/AIDS programmes. The question that should be asked is what steps are needed at this stage to minimise this impact of HIV/AIDS over the short to medium term. Fortunately, as more donor aid is being poured into the region and generic AIDS drugs in recent years by African states, principally South Africa, are manufactured, more HIVpositive persons in the region are living longer lives than ever before. Despite the devastating consequences wrought by the disease over the past decade on the region’s social and economic well-being, there is an opportunity for these countries to tackle the disease and bring it under control. This has transpired over the past few years in Uganda and to a lesser degree in Zimbabwe. Fortunately, the virus is unable to spread through casual human contact, and the availability of low-cost generic drugs offers a lifeline to many HIV-positive people in these southern African countries. In addition, governments are waging better AIDS awareness campaigns that are strengthened by media emphasis on safe sex practices. In view of all of these efforts there is increased hope that the chance of succeeding in the battle to control the spread of HIV/AIDS has never been better. What is needed currently is a better coordination among all sectors of society, including government, business, and civil society, to pull their resources together in order to promote interventions to help treat and control the disease. Governments and the private sector are encouraged to work together to mitigate the problems caused by HIV/AIDS by way of: • ensuring that safe blood supplies are available in hospitals; • promoting safe sex education in schools; • making counselling, testing, and treatment available and administered to local populations; and • making sure that the human rights and dignity of all HIV-positive people are respected in all sectors of society and raising awareness among the general population that HIV-positive individuals can live long, productive lives and contribute to their communities at large. With the vast majority of the people of those countries remaining HIV-negative, there is increasing hope among African governments and donor communities alike that all is not lost for southern Africa to turn back the tide and take control over the fight against this preventable disease.
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Notes 1 The Global Fund to Fight AIDS, Tuberculosis, and Malaria was launched in 2002 to direct resources toward fighting three of the world’s most devastating diseases. With respect to the battle to contain HIV, the Global Fund had hoped to provide 62 million with voluntary counselling and testing services for HIV prevention, to support 1 million orphans through medical services, education, and community care, and to supply 1.8 million with ART over a five-year period. 2 PEPFAR (2008) was a commitment of US$15 billion over five years (2003–2008) from U.S. president George W. Bush to fight the global HIV/AIDS pandemic. As the largest international health initiative ever initiated by one state to address a single disease, the programme hopes to prevent 7 million new infections, to provide ART to 2 million HIVinfected people in resource-limited settings, and to support care for 10 million people. 3 The official figures the National HIV Estimates Process for 2005 and 2003 were 20.1 percent and 24.6 percent respectively (Zimbabwe National Monitoring and Evaluation Taskforce 2008).
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Garbus, Lisa (2003). HIV/AIDS in Zambia. Country AIDS Policy Analysis Project, March. University of California, San Francisco. <ari.ucsf.edu/programs/policy/countries/Zambia. pdf> (September 2008). Gregson, Simon, Geoffrey P. Garnett, Constance A. Nyamukapa, et al. (2006). ‘HIV Decline Associated with Behaviour Change in Eastern Zimbabwe.’ Science, vol. 311, no. 5761, pp. 664–666. <www.sciencemag.org/cgi/content/abstract/311/5761/664> (September 2008). Haacker, Markus (2001). ‘Providing Health Care to HIV Patients in Southern Africa.’ In B. Granville, ed., The Economics of Essential Medicines (London: Royal Institute of International Affairs). Hallett, Timothy B., John Aberle-Grasse, George Bello, et al. (2006). ‘Declines in HIV Prevalence Can Be Associated with Changing Sexual Behaviour in Uganda, Urban Kenya, Zimbabwe, and Urban Haiti.’ Sexually Transmitted Infections, vol. 82 (suppl. 1), pp. i1–i18. <sti.bmj.com/cgi/content/full/82/suppl_1/i1> (September 2008). Human Rights Watch (2005). ‘Clear the Filth’: Mass Evictions and Demolitions in Zimbabwe. September. New York. <www.hrw.org/backgrounder/africa/zimbabwe0905> (September 2008). Human Rights Watch (2006). No Bright Future: Government Failures, Human Rights Abuses, and Squandered Progress in the Fight against AIDS in Zimbabwe. Vol. 18, No. 5(A). <www.hrw.org/reports/2006/zimbabwe0706/zimbabwe0706webwcover.pdf> (September 2008). Hunter, Mark (2007). ‘The Changing Political Economy of Sex in South Africa: The Significance of Unemployment and Inequalities to the Scale of the AIDS Pandemic.’ Social Science and Medicine, vol. 64, no. 3, pp. 689–700. Kalideen, Nalisha and Molpone Malefane (2005). ‘Mandela in Mourning after His Son’s Death.’ Independent Online, 7 January. <www.iolhivaids.co.za/index.php?fArticleId=29 12539&fSectionId=1592> (September 2008). Khomanani (2008). Department of Health South Africa, Pretoria. <www.aidsinfo.co.za> (September 2008). Knight, Richard (2006). ‘South Africa 2006: Population and HIV/AIDS.’ South African Delegation Briefing Paper, November. Shared Interest, New York. (September 2008). Laurance, Jeremy (2008). ‘Threat of World AIDS Pandemic among Heterosexuals Is Over, Report Admits.’ Independent, 8 June. Lehohla, Pali (2006). ‘Knowing Causes of Death Is Crucial for Planning.’ Business Report, 14 September. <www.statssa.gov.za/news_archive/14September2006_1.asp> (September 2008). Lewis, Stephen (2006). ‘Keynote Address at the Closing Session of the XVI International AIDS Conference.’ Closing Session of the XVI International AIDS Conference, 18 August. Toronto. <www.stephenlewisfoundation.org/news_speech_item. cfm?news=1382&year=2006> (September 2008). Mahomva, Agnes (2004). ‘Trends in HIV Prevalence and Incidence and Sexual Behaviour.’ Presentation to the UNAIDS Reference Group on Estimates, Modelling, and Projections, 15–17 November. Harare. Mahomva, Agnes, Stacie Greby, Sabada Dube, et al. (2006). ‘HIV Prevalence and Trends from Data in Zimbabwe, 1997–2004.’ Sexually Transmitted Infections, vol. 82, suppl. 1, pp. 42–47.
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Mugurungi, Owen, Simon Gregson, A.D. McNaghten, et al. (2007). ‘HIV in Zimbabwe: Measurement, Trends, and Impact.’ In M. Caraël and J.R. Glynn, eds., HIV, Resurgent Infections, and Population Change in Africa. Heidelberg: Springer. National AIDS Coordinating Agency (Botswana) (2003). The National Strategic Framework for HIV/AIDS 2003–2009. Gabarone. <www.naca.gov.bw/documents/NSF%20final2.pdf> (September 2008). National HIV and AIDS and TB Unit (South Africa) (2006). ‘HIV/AIDS.’ Department of Health South Africa, Pretoria. <www.doh.gov.za/aids> (September 2008). Palitza, Kristin (2006). ‘Health—South Africa: A Burden That Will Only Become Heavier.’ Inter Press Service, 28 May. (September 2008). Pembrey, Graham (2008). AIDS in South Africa: Treatment, Transmission, and the Government. AVERT. <www.avert.org/aids-south-africa.htm> (September 2008). South Africa (1998). ‘Partnership against AIDS Declaration.’ 9 October. Pretoria. <www.info. gov.za/issues/hiv/aidsdeclaration.htm> (September 2008). South Africa (2003). Operational Plan for Comprehensive HIV and AIDS Care, Management, and Treatment for South Africa. 19 November. Pretoria. <www.info.gov.za/otherdocs/2003/ aidsplan> (September 2008). South Africa (2005). ‘Implementation of the Comprehensive Plan on Prevention, Treatment, and Care of HIV and AIDS: Fact Sheet.’ 23 November. South African Government Information, Pretoria. <www.info.gov.za/issues/hiv/implementation2006.htm> (September 2008). South Africa (2006). Progress Report on the Declaration of Commitment on HIV and AIDS. Prepared for the United Nations General Assembly Special Session on HIV and AIDS, February. <www.doh.gov.za/docs/reports/2006/ungass/part1.pdf> (September 2008). South Africa (2008). ‘HIV/AIDS.’ FAQs. Pretoria. <www.info.gov.za/faq/aids.htm> (September 2008). South Africa. Department of Health (2007). Report National HIV and Syphilis Prevalence Survey, South Africa 2006. Pretoria. <www.doh.gov.za/docs/reports/2007/hiv> (September 2008). South African Advertising Research Foundation (2004). All Media Products Survey. March. Sloane Park. Statistics South Africa (2003). Census 2001: Census in Brief. Report no. 03-02-03 (2001). Pretoria. <www.statssa.gov.za/census01/html/CInBrief/CIB2001.pdf> (September 2008). Steinberg, Malcolm, Saul Johnson, Gill Schierhout, et al. (2002). Hitting Home: How Households Cope with the HIV/AIDS Epidemic. October. Kaiser Family Foundation, Omaha. <www.kff.org/southafrica/20021125a-index.cfm> (September 2008). Swaziland Central Statistical Office (2008). Swaziland Demographic and Health Survey 2006–07. May. Mbabane. <www.measuredhs.com/pubs/pdf/FR202/FR202.pdf> (September 2008). UNAIDS (2004). Zambia. Epidemiological Fact Sheets. Geneva. (September 2008). UNAIDS (2005a). Evidence for HIV Decline in Zimbabwe: A Comprehensive Review of the Epidemiological Data. Geneva. (September 2008). UNAIDS (2005b). ‘AIDS Epidemic Update: December 2005.’ <www.unaids.org/epi/2005/ doc/EPIupdate2005_html_en/epi05_00_en.htm> (September 2008). UNAIDS (2008). ‘South Africa.’ Geneva. <www.unaids.org/en/CountryResponses/Countries/ south_africa.asp> (September 2008).
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Chapter 9
The Renovation of Institutions to Support Drug Access: Is it Enough? Jillian Clare Cohen-Kohler1
Pharmaceutical policy is a good example of the most basic resource allocation questions of who gets what and how much. Governments around the world struggle to find ways to produce public policies that can lead to happy outcomes in both the health and economic areas. But the struggle between satisfying commercial interests and fulfilling public health needs in the pharmaceuticals area is often uneasy and messy. This is seen most clearly when examining the impact of international trade imperatives on access to medicines. Moreover, despite the general awareness of the importance of access to essential medicines, too many of the world’s poor are faced with limitations. Despite unprecedented levels of international funding, thanks largely to the influx of aid to health from private donors, and a plethora of programmes devoted to improving global pharmaceutical access, there remains a drug gap, which constitutes a major moral conundrum in international drug policy. When 15 �������������������������������������������������������������������������� percent of the world’s population consumes more than 90 percent of the world’s pharmaceuticals, there is a crisis in health ��������������������������������� (Oxfam International 2007)������� .������ With this knowledge, one might assume that efforts would be made to identify what factors are causing this gap and to correct them. But this is not the case, particularly with regard to the impact of international trade law on drug access. As Joseph Stiglitz (2006, 59) points out in discussing development gains, there are few success stories … The rest of the world cannot solve the problems of the developing world. They will have to do that for themselves. But we can at least create a more level playing field. It would be even better if we tilted it to favor the developing countries.
As part of a move to make conditions more favourable for developing countries, access to essential medicines is now a central topic at the international policymaking level. It is expressed as a fundamental human right, with international human rights law placing attendant obligations on states to ensure access (Cullet 2003). Specifically, established in 2000, article 12 of the United Nations International Covenant on Economic, Social, and Cultural Rights outlines the ‘right to the highest
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attainable standard of health’, which includes the right to the availability of essential medicines as defined by the World Health Organization (WHO) (United Nations Economic and Social Council Committee on Economic, Social, and Cultural Rights [CESCR] 2000).2 Through the legal obligations to respect, protect, and fulfil the right to health, governments have implicit duties to ensure that pharmaceutical systems are institutionally sound and fair and that patients who need drugs get them. This is a relatively novel view and suggests that blind faith in the primacy of commercial interests is being challenged by alternative paradigms that put social issues squarely on the top of any agenda. To be sure, pharmaceutical research and development (R&D) have value and promise. In the past 50 years, there has been large-scale production of drugs that save or enhance life. Important advances have been made in diseases such as heart disease, diabetes, and cancer as well as HIV/AIDS and cystic fibrosis. But there has been also an undeniable slow-down in pharmaceutical R&D. As Marcia Angell (2004, 14) writes, ‘the stream of new drugs has slowed to a trickle, and few of them are innovative in any sense of the word. Instead, the great majority are variations of oldies but goodies—“me-too” drugs’. The structure of the industry has also changed in recent decades with the megamergers of companies. Commercially friendly policy such as tax concessions and the rigorous application of intellectual property law have become even more critical for the robustness of an industry accustomed to a high rate of return on its capital investment. While supporting industry is desirable for governments from an economic perspective, for the simple reason that governments want to attract investment, a dilemma arises from pharmaceutical policy, because supportive commercial policy may undermine health outcomes of the international standards for pharmaceutical patents. The construction of the international regime—the World Trade Organization (WTO) in 1995 and the Trade-Related Aspects of Intellectual Property Rights (TRIPS) Agreement are cases of the primacy of the economic model in international institutions. But this chapter shows that the hegemony of commercial interests is increasingly being challenged by alternative paradigms that put social issues such as the right to medicines first. The value of having global governance in place when it affects national health outcomes needs to be re-examined, particularly when those international institutions are guided by principles of economics. John Ralston Saul points out that globalisation is flawed in that it is imagined through the lens of economics. He writes that ‘the central perception of Globalization is that civilization should be seen through economics, and economics alone’ (Saul 2005, 35). Globalisation has meant the lessening of competition through monopolies such as those permitted under the TRIPS Agreement. It is not necessarily a positive phenomenon for those who stand to lose considerably. The primacy accorded to economic models needs to be rethought, particularly when faced with potentially devastating effects on social policy as a result of their application. This is the case in the pharmaceutical sector, particularly in relation to the application of the TRIPS Agreement. This chapter illustrates how concerns about health are slowly infiltrating economic paradigms.
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An initial question serves as a backdrop to this chapter: is globalisation a positive phenomenon in terms of its impact on the pharmaceutical market? Globalisation is not being criticised as such, as that is a losing proposition. But globalisation can mean the imposition of standards and designs that may be inappropriate or vastly different from local ones. In this case, often there is a push-pull dynamic between global and local standards, which may lead to very different results depending on the incentive structure and institutions the individual must navigate. Dani Rodrik (1997, 82) argues that multilateral institutions need to encourage a greater convergence of policies and standards with ‘deep integration’ only among those countries that are willing to do so in order to reduce tensions from the differences in national standards. They must also allow for selective disengagement from multilateral standards for countries that need breathing room to satisfy domestic requirements that conflict with liberalising trade. International agreements that have the potential to affect, directly or indirectly, the health of populations, particularly those in the poorest countries, must be structured with safety valves that can enable a country to maintain good international standing if it decides not to commit to standards that are too costly in terms of health objectives. It may be difficult to determine when countries are cheating, but this should not impede efforts to infuse international agreements with inclusions that can help protect the health of populations. This concept is not novel. Efforts have been made in the past to ensure that there are inclusions for health in trade agreements. But are these provisions adequate for ensuring equitable access to pharmaceuticals?
Methodology and Organisation This chapter is restricted to documentary analysis, which includes the interpretation of the TRIPS Agreement, international statements, and other pertinent documents. It first examines how globalisation has been dominated by economic paradigms and how the primacy of economic models is challenged by alternative social paradigms such as those that view access to medicines as a basic human right. Next is an examination of the TRIPS Agreement and its implications for pharmaceutical access as well as possible policy levers, which a state can apply and which can ideally mitigate the harshest impact of the TRIPS Agreement. Then discussion deals with select international statements, considering the value of health and the implications of these for the imposition of trade agreements. Finally, the chapter concludes by discussing the relative merits of the health inclusions and proposes changes. As Sabina Alkire and Lincoln Chen (2004, 1074) point out, ‘appeal to moral values will motivate people to support a set of actions’. The infusion of ethical considerations, such as ensuring that everyone has fair access to essential medicines, into international governance structures has been aided by the growing focus on health as a human right. Given that human rights are universal, health squarely takes primacy over any trade agreement. But how does one ensure this happens given the hegemony of commercial concerns?
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The TRIPS Agreement: Shining the Spotlight on the Potential Schism between Trade and Health The TRIPS Agreement was one of the many agreements that resulted from the Uruguay Round multilateral trade negotiations, which took place from 1986 to 1994. It covers a range of intellectual property issues such as patents, trademarks, industrial design, and copyright. It requires each member state to maintain sufficient procedures and remedies within its domestic law to ensure the protection of intellectual property for both domestic and foreign rights holders. More specifically with regard to pharmaceuticals, there are four minimum legal obligations. First, pharmaceutical products and micro-organisms are patentable for up to 20 years from the date the inventor files for patent application. Second, discrimination against patent rights for imported products is not permitted. Third, exclusive marketing rights are granted until patent expiry. Fourth, there is a transitional period of one year, which can be extended to up to ten years, for developing countries without pharmaceutical product patents (Redwood 1995). According to the WTO (undated), its ‘framework ensures that membership in the WTO entails accepting all the results of the Round, without exception’, so members must comply with the TRIPS requirements as part of membership conditionality. The TRIPS Agreement does, however, include provisions that allow developing countries some breathing space in terms of its applicability. In theory, Rodrik’s call for selective disengagement provisions is embedded into the agreement. For one, the agreement allows developing countries a general transition period of up to five years to amend their patent legislation so that it meets WTO standards. A longer time, up to ten years, is allowed for developing countries without prior patent protection for pharmaceutical products, such as countries that have ‘process’ patents in place but no protection for the final product. Least developed countries (LDCs) were originally given up to eleven years, later extended to 2016 when it became obvious that the initial timeline was unrealistic for implementation. There is still some reasonable doubt that even these extended deadlines will be met. However, political and economic realities easily deter countries from making use of these provisions. Advocates of the TRIPS Agreement argue that sufficiently applied pharmaceutical patent regimes are a sine qua non for large multinational pharmaceutical firms to invest resources in the R&D of new drug therapies. But R&D expenditure does not even remotely address the needs of developing countries. If trends are examined, little potential is seen for the reallocation of activities toward diseases of the poorest countries. Médecins Sans Frontières ([MSF] ��������������������������������������� 2003)��������������������������� estimates that 90 percent of the world’s health R&D expenditure is devoted to conditions that affect just 10 percent of the world’s population, with priority conditional upon ability to pay. This prioritisation of diseases affecting the developed world is reflected in the fact that of 1393 new drugs approved between 1975 and 1999 only 13 were specifically indicated for tropical diseases (Trouiller et al. 2002)����������������������������������� . Tropical diseases largely affect poor populations and account for 12 percent of the global disease burden (MSF 2001)��.
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A more recent review, which �������������������������������������� updated the database to include new chemical entities (NCEs) to 2004, found that out of 1556 NCEs, only four were for neglected diseases (malaria and leishmaniasis) (Chirac and Torreele 2006). In addition, the poor people of developing countries are suffering the double burden of communicable and noncommunicable diseases (Commission on Intellectual Property Rights, Innovation, and Public Health 2006, 3). This ������������������������������������������������ raises ������������������������������������������� the ������������������������������������ question of why is the focus on R&D for the poorest countries so limited. Are ethical considerations completely absent from the decision-making process? The Commission on Intellectual Property Rights, Innovation, and Public Health (CIPIH) reported in 2006 ���������������������� that R&D continues to favour disproportionately the health needs of the latter. It quickly concluded that any incentive for innovation is pointless if developing countries cannot take part in the benefit. In other words, neglected people should be the main concern when innovating new drugs. The crucial link between health and development cannot be understated. The CIPIH stated that the ‘reduction of poverty itself is … one of the most important contributions to improving health. However, while poverty predisposes people to ill-health, ill-health also reinforces poverty … Promoting health and promoting development are complementary—one cannot be achieved without the other’ (7). Additionally, why are governments and universities not looking more actively for ways to remedy this situation? To be sure, there are efforts underway through civil society such as the Drugs for Neglected Disease Initiative and the student-led Universities Allied for Essential Medicines. Detractors of the TRIPS Agreement point out that the treaty exacerbates the inequity in pharmaceutical drug gaps. These fears are grounded for a number of reasons. Prior to the agreement, the pharmaceutical patent regime of developing states was, for the most part, considerably below the minimum criteria of TRIPS. Many developing states, such as India and Brazil, adopted an explicit policy to disregard intellectual property protection for pharmaceutical products in order to facilitate self-sufficiency in the production of basic medicines and to develop a competitive local industry. Domestic producers, both private and public, could then supply their populations with basic medicines at prices often considerably lower than those of the research-based pharmaceutical industry and build a viable industry through reverse engineering, as in the case of India and Brazil. Critics of the agreement also point out that its implementation results in higher prices for drugs, widens the access gap between developed and developing countries to essential medicines, further increases imbalances in the R&D of drug therapies between developed and developing countries, and threatens the viability of local industry by negatively affecting local manufacturing capacity. Moreover, longer patent regimes prevent generic competition that in turn helps make pharmaceuticals more affordable. Generic competition significantly reduces drug prices, if the correct market structures are in place. Pharmaceutical product prices fall sharply when generic entry occurs following the expiration of patents (Scherer 2000). Critics also argue against protecting an industry that has not demonstrated enough social concern in its activities. As Ken Shalden (2007) points out in a thoughtful analysis about what is problematic about regulation of intellectual property, such regulation changes
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market structure and thus influences economic interests and capabilities, forming ‘new constellations of interest’ that may in fact be detrimental to drug supply. In short, the TRIPS Agreement is a product of extensive negotiations and thus includes provisions that demonstrate where concessions were made, particularly for developing countries and LDCs, which were concerned about its impact on drug access. It contains provisions that may be used by governments to ensure that health objectives are not compromised. But even though the text of the agreement suggests the potential for governments to put health needs over trade needs, the reality for many developing countries and LDCs is that they may not make use of the provisions because of administrative, political, and knowledge barriers. The agreement itself affects actors’ interests as well as their capabilities for action. Still, the provisions that potentially benefit governments demonstrate the potential health safety valves are embedded in the agreement. These provisions have subsequently been supported by a number of international institutions.
Challenges to the Primacy of the Paradigm of Commercial Interests The TRIPS Agreement is an interesting hybrid of economic logic (support for industries that do R&D) and social inclusions that offer some limited relief from the heaviness of economic imperatives. The inclusion of health safety valves in the agreement has been endorsed by the UN’s Economic and Social Council, which analysed the agreement for its health and human rights implications in 2002. Of relevance here is the aforementioned article 12 of the International Covenant on Economic, Social, and Cultural Rights, which obliges ‘States Parties … recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health’ (UN Office of the High Commission for Human Rights [UNHCHR] 1966). The CESCR (2000) set out the content of this right in General Comment No. 14. Relevant to this discussion are the obligations on states to promote a number of health objectives. First, the convenant puts a positive obligation on states to promote research with particular regard to diseases such as HIV/AIDS. Second, states must take into account the particular situation of HIV/AIDS and other epidemics in the right to health. Third, the obligations related to the right to health require states ‘to refrain from interfering directly or indirectly with the enjoyment of the right to health. The obligation to protect [the right to health] requires States to take measures that prevent third parties from interfering with article 12 guarantees … [and] the obligation to fulfil requires States to adopt appropriate legislative, administrative, budgetary, judicial, promotional and other measures towards the full realization of the right to health’ (CESCR 2000, para. 33). Fourth, states and private actors are obliged to give ‘due attention in international agreements and … States parties should take steps to ensure that these instruments do not adversely impact upon the right to health’ (para. 39). They also have international obligations to ‘provide essential drugs’ and to ‘take measures to prevent, treat and control epidemic and endemic diseases’ (para. 43[d], para. 44[c]).
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The UN Economic and Social Council Commission on Human Rights (2001) also stresses the importance of health as a human right in the context of TRIPS. It makes two points. First, it emphasises, ‘a human rights approach requires that the public/private balance under article 15 [of the CESCR] should be struck with the primary objective of promoting and protecting human rights.’ Whatever ‘balance is struck between private and public interests in intellectual property, the balance should not work to the detriment of any of the other rights in the Covenant’. Second, it notes that intellectual property rights are ‘more akin to a privilege’. Intellectual property rights [IPRs] ‘can be licensed or assigned to someone else, they can be revoked, and they eventually expire. Similarly, IPRs can be—and often are—held by corporations. Human rights, on the other hand, are inalienable and universal. They are not granted by the State, they are recognized.’ Finally, and most importantly, the CESCR General Comment calls for ensuring access to affordable treatments. This is best summarised by Report of the High Commissioner for the Commission on Human Rights (UN Economic and Social Council Commission on Human Rights 2001, 10–11): States are bound to promote the right to health through the ensuring access to affordable treatments. The right to health contains certain essential elements to be applied by States according to the prevailing national conditions. These elements include ensuring the availability, accessibility, acceptability and quality of health facilities, goods and services. The second element of accessibility includes the notion of affordability—health facilities, goods and services must be affordable for all, whether privately or publicly provided … The right to facilities, goods and services also includes the provision of essential drugs [emphasis added].
The UN Declaration of Human Rights (1948) is similar to article 12 of the international covenant. Article 25(1) of the declaration expresses that ‘everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including … medical care’. This is arguably weaker than the former statement stressing the ‘highest attainable standard’, rather than the declaration’s ‘adequate for health’. Still, given that human rights are universal and inalienable, the call for adequate health and well-being could trump any trade provision that limits access to essential medicines. This raises the question of whether the possible policy-release provisions within the TRIPS Agreement are sufficient to ensure health is not compromised by trade considerations. One potential policy ‘release’ from the TRIPS Agreement is article 27.2, which allows a government to deny patent protection for specific inventions. This restriction on the patentability of inventions in order to protect ‘human, animal or plant life or health’ allows governments the freedom to give priority to human life or health in order to protect ‘ordre public’ (WTO 1994). There is no universally accepted definition of what this term means so it potentially gives a government ample scope for its use. Of equal importance, article 31(f) of the TRIPS Agreement permits countries with a public health crisis to forgo patent law and issue a compulsory
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license to a local manufacturer. Members’ freedom to do so is explicitly articulated in article 8, which authorises members to ‘adopt measures necessary to protect public health and nutrition, and to promote the public interest in sectors of vital importance to their socio-economic and technological development’, provided that such measures are consistent with the TRIPS Agreement (WTO 1994). Furthermore, article 6 does not prohibit the parallel import of drug products. Countries that have relatively high drug prices in their domestic market are free to import a patented product from a country where it is priced lower. While these provisions in the agreement indicate that states can adopt measures necessary to ensure access to medicines for all, in practice many governments have not applied these safeguard provisions (Cullet 2003, 139–160). The reasons are many. They include the lack of capacity to make use of provisions (such as in the case of compulsory licensing, which until the 2001 Declaration on the TRIPS Agreement and Public Health required a country to have manufacturing capability), restrictive legislation not in line with international legislation, and political pressure to respect intellectual patent law for pharmaceuticals and thus not to make use of potential health safeguards. One case of the political pressure that can be brought to bear on a state perceived to be non-compliant is the use of the Special 301 Report by the United States Trade Representative (USTR) (Drahos 2001).3 A remark made by a USTR official puts into perspective the powerful nature of this tool: One fascinating aspect of the Special 301 process occurs just before we make our annual determinations, when there is often a flurry of activity in those countries desiring not to be listed or to be moved to a lower list. IP laws are suddenly passed or amended, and enforcement activities increase significantly (Fisher 1999, cited in Drahos 2001, 3).
Notwithstanding, from a purely legal perspective, the TRIPS Agreement has room to move because of the imprecision of its language and its relative youth in legal terms. There are some terms without clear definitions or without concrete legal precision in the agreement. While these indefinite terms will be subject to certain international interpretative principles (such as the Vienna Convention on the Law of Treaties; see UN 1969), such principles also allow the values of the agreement to be interpreted and applied. Some of the TRIPS articles can be used to interpret the ‘objectives and principles’— i.e., underlying values—of the agreement for future definitional impreciseness. These include the preamble and articles 7 and 8. The preamble includes the provision that the TRIPS Agreement recognises the need for ‘adequate standards and principles concerning … trade-related intellectual property rights’, rather than high or very high standards (WTO 1994). Another is the recognition that ‘the special needs of the least-developed country Members in respect of maximum flexibility in the domestic implementation of laws and regulation in order to enable them to create a sound and viable technological base’. This could be used, for example, to strengthen the case for certain developing countries to emulate India’s success with the generic drug industry and further forgo certain TRIPS obligations.
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Article 7 states that the intellectual property protection, while contributing to technological innovation, should also contribute to ‘the transfer and dissemination of technology, to the mutual advantage of producers and users of technological knowledge’ (WTO 1994). Furthermore, it says that this should be ‘in a manner conducive to social and economic welfare and to a balance of rights and obligations’. The evidence to date on this provision has been paltry. Sometimes, these values need to be cleared up, strengthened, or even changed. The Declaration on the TRIPS Agreement and Public Health was one of these interpretative clarifications. It was a result of pressure from developing country governments and health activists who expressed concerns that the so-called health safeguard provisions in the TRIPS Agreement were simply inadequate to guarantee access to medicines. Whether the declaration was a clarification, strengthening, or change is debatable. But, more importantly, articles 1 to 5 of the declaration were used to interpret articles 31 of the TRIPS Agreement, in particular, articles 31(b) and 8 (WTO 2001; 1994). The declaration even stated that, in article 5(a), ‘in applying the customary rules of interpretation of public international law, each provision of the TRIPS Agreement shall be read in the light of the object and purpose of the Agreement as expressed, in particular, in its objectives and principles’. Moreover, the declaration boldly asserted health as a value in international agreements, even those ostensibly outside the health sector.
Putting Health First? The Declaration on the TRIPS Agreement and Public Health In view of the real and perceived imbalances expressed in the TRIPS Agreement, the Declaration on the TRIPS Agreement and Public Health was drafted in order to provide more security to developing countries so that public health priorities would not be threatened by the exigencies of the agreement. The declaration boldly asserts: We agree that the TRIPS Agreement does not and should not prevent members from taking measures to protect public health. … we affirm that the Agreement can and should be interpreted and implemented in a manner supportive of WTO members’ right to protect public health and, in particular, to promote access to medicines for all (WTO 2001).
M. Gregg Bloche (2002, 831) points out that health has emerged as a value in international trade law. He has also underscored that the main WTO agreements are vague regarding balancing public health against other trade-related concerns (825). The declaration was partially an effort to interpret article 31(f) of the TRIPS Agreement, which states that compulsory licensing shall be ‘predominantly for the supply of the domestic market’ (WTO 1994). This highly debated provision was futile for the poorest countries that do not have manufacturing capacity. That means, under WTO rules, countries with a public health crisis are able to forgo patent
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law and issue a compulsory licence to a local manufacturer. But, given that the majority of developing countries lack the domestic capacity or technical expertise to manufacture pharmaceuticals, the interpretation of this terminology is crucial for ensuring access to medicine for the poor in many developing countries. As such, the declaration includes the now well-analysed paragraph 6, which recognises the limitations of the terms of compulsory licensing for member countries of the WTO, particularly the LDCs that cannot turn to local producers for the manufacture of medicines (WTO 2001). It calls for an expeditious solution to the problem. As a result of uncertainty about the interpretation and reach of the declaration, lengthy and highly acrimonious discussions ensued among the WTO members that largely put the interests of countries such as the United States against those of developing countries. But after a year and a half of debate, lobbying, and global public outrage about the debate, a decision was finally reached on 30 August 2003. The decision clarifies the right of countries to take advantage of compulsory licensing for pharmaceutical products only in the case of a national emergency in order to address public health problems covered by paragraph 1 of the declaration (WTO 2003). It also permits countries without manufacturing capabilities to turn to a third country, such as Canada (through Bill C-9 on Export of Medicines), for the export of medicines. Finally, the decision reaffirms the right of governments to interpret the TRIPS Agreement in a manner that supports their right to protect public health. It highlights the need for the TRIPS Agreement to be interpreted in such a way as to protect public health and not for commercial policy objectives. But the decision does not mean the seamless application of compulsory licensing for developing countries without manufacturing capabilities. There are a number of administrative procedures, such as requiring both the importing and exporting countries to issue compulsory licenses, ensuring that the WTO is involved in the overseeing of the procedures, and other stipulations contained in the accord that could effectively limit its application. In addition, many developing countries do not have the necessary administrative infrastructure and know-how to make use of the compulsory licensing provision. Still, irrespective of these potential constraints, the accord sets an important precedent of ensuring that international trade law does not ignore the importance of public health necessities. Patients ideally should be taking precedence over patents. It provides, however imperfectly, the potential for countries to disengage from the exigencies of global governance—the TRIPS Agreement. But despite its potential to do good, its true value is still in question. To date, it remains an international source of shame that not one country that reformed its patent law to export medicines to countries in need has actually done so. Canada is one of the worst offenders, as promises that were expressed through what is now known as the Canadian Access to Medicines Regime (CAMR) were bold in 2003 have yet to be fulfilled. What is more, ‘TRIPS-plus’ bilateral and regional treaties forged by the USTR continue to be a threat to the effectiveness of any social inclusion in international trade law.
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Conclusion This chapter has focussed on how the domination of commercial interests is being challenged by social ones. The TRIPS Agreement includes provisions that protect health but these provisions have not had much weight. This reality led health activists and developing country governments to pressure the WTO for meaningful support for health concerns. Their efforts were also facilitated by support in the court of international public opinion, which was particularly outraged by the lack of access to antiretroviral treatment (ART) in developing countries. As a result, the 2001 declaration was signed. Another lengthy process of negotiation followed, ending in 2003 when governments were able to reach consensus on issues such as the use of compulsory licensing, particularly for those countries that lacked the manufacturing capacity to make use of it. Since the creation of the WTO, international statements and agreements have emphasised that health is a value that must be protected. The final word is that in order to offer adequate protection for health and, in particular, access to medicines, the WTO still needs to undergo a seismic shift in its institutional orientation to ensure that patents do not trump health. There has been blind faith in the primacy of economics and thus social issues have been submerged or added on to economic models. There is a need for constructive thinking about governance so as to renovate institutions by ensuring that health issues are not superseded by commercial one. But in the final analysis, is renovation good enough? Or is a complete demolition necessary, or even possible? The likely answer is that the changes now being made to international governance to ensure that public health imperatives are upheld and respected are still insufficient. There have been inclusions that potentially allow governments to make sure that their populations have access to medicines, even with the imposition of standards such as international patent law. But what ultimately counts is whether governments are using these provisions well and what is happening in their healthcare systems. While countries such as Thailand, Brazil, and others use their right to compulsory licensing, political and economic pressures are forcing many governments to turn a blind eye to their obligation to ensure that they fulfil their population’s right to the highest attainable standard of health. Notes 1 The author is grateful to Emily Ng and Greg Kukowara for their research assistance and to Andrea Perez Cosio and Vicky Kuek for their comments and edits. 2 Paragraph 12a explicitly states that ‘essential drugs, as defined by the WHO’s Action Programme on Essential Drugs should be made available in ‘sufficient quantity’ (CESCR 2000). The exact application of this clause depends on the conditions in a state. 3 Section 301 of the U.S. Trade Act is, according to Peter Drahos (2001, 3), ‘used by the USTR to address foreign unfair trading practices, including unfair practices on intellectual property rights’.
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Chapter 10
Global Health Governance from Below: Access to AIDS Medicines, International Human Rights Law, and Social Movements Lisa Forman
Any global effort to achieve health for all must respond to the inaccessibility of affordable and essential medicines in many developing countries. This dearth of fundamental healthcare goods and services threatens human development and social prosperity. Global governance by international organisations and governments in this area has largely been inadequate and inefficient, serving to perpetuate and entrench the status quo, which has prioritised the interests of pharmaceutical companies in the West over the human needs of the global poor. Global civil society actors challenged this status quo in relation to AIDS medicines, moving international organisations and governments alike toward collective action to facilitate access to these medicines in developing countries. This struggle has coalesced around human rights claims, litigation, and mobilisation. This chapter explores the contribution of global social movements to the issue of access to AIDS medicines and their implications for the utility of rights-based discourse and legal actions in global health governance. It outlines the broader challenge posed by inaccessible medicines, and focusses on the specific problem of AIDS medicine; it illustrates the inadequacies of global responses to this problem, and describes the emergence of global social activism. It explores the changes and innovations achieved through this activism, and closes by analysing the implications of this struggle for global health governance more generally.
Global Access to Medicines Medicines are a fundamental component of a healthcare system and a core element of any government’s efforts to meet the healthcare needs of its populace. They are ‘by far the most significant tool that society possesses to prevent, alleviate and cure disease’ (United Nations Millennium Project 2004, 9). Yet almost 2 billion people (one third of the global population) lack regular access to essential medicines (World
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Health Organization [WHO] 2004b, 3). This figure rises to over half the population in some low-income countries in Africa and Asia. While these figures suggest a gross inequity in drug access, it is notable that they refer only to essential medicines, a category of medicines defined by the WHO (2007a) as ‘those that satisfy the priority health care needs of the population’. In the past, the WHO has selected these medicines primarily on the basis of cost effectiveness and affordability. Thus drugs that effectively treat disease yet were expensive were excluded from the list as a matter of course. This was the case with HIV/AIDS medicines (before the WHO included them in response to activist pressures) and artemisinin-based anti-malarial drugs, and remains the case for tuberculosis (TB) treatments and reserve antibiotics. Access to medicines to treat many priority healthcare needs such as HIV/AIDS or malaria is considerably lower than even these figures suggest. The impact of inaccessible medicines is exacerbated by the growing double burden of communicable and non-communicable disease in developing countries (Commission on Intellectual Property Rights, Innovation, and Public Health [CIPIH] 2006, 15). Communicable diseases cause devastating rates of mortality in these regions, led by HIV/AIDS in sub-Saharan Africa as well as resurgent malaria and TB. For example, 2 million people died from HIV/AIDS in 2007 (UNAIDS 2008, 15); more than 1 million people (mainly African children) die from malaria each year and 1.7 million people died from TB in 2007 (mainly due to opportunistic infections in people with HIV/AIDS) (WHO 2007b; WHO 2008). This dearth of medicines is similarly illustrated by the skewed consumption of medicines between rich and poor countries. In 2005, pharmaceutical sales in Latin America, southeast Asia, the Indian subcontinent, Africa, and the Middle East combined amounted to only 12.1 percent of global sales (CIPIH 2006, 15). In contrast, drug consumption in North America, Europe, and Japan amounted to more than 85 percent of the global pharmaceutical market. In other words, one fifth of the world’s population who are located in developing countries purchase almost two thirds of the world’s pharmaceuticals. The persistent inaccessibility of many affordable medicines suggests that both poverty and political neglect play key roles. Yet these factors provide insufficient explanations for the global drug gap and, as the WHO’s Commission on Intellectual Property Rights, Innovation, and Public Health (2006, 16) indicates, drug pricing and overall cost of treatment constitute a major problem in developing countries. In developing countries, medicines can account for between 25 percent and 70 percent of total healthcare expenditures, compared to under 15 percent in many high-income countries (WHO 2004b, 14). Drugs also consume 50 percent to 90 percent of outof-pocket spending on health in developing countries (14). Reducing drug prices is therefore a critical strategy in ensuring broader access to medicines, and this is true for HIV/AIDS and TB medicines as well as for drugs to treat non-communicable diseases such as cancer and diabetes. Several factors determine drug prices, including manufacturer’s prices, transport and storage costs, import tariffs and taxes, procurement practices, and dispensing fees (Henry and Lexchin 2002). However, patents are broadly recognised as the
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most significant determinant of drug prices (Caves et al. 1991; Abbott 2002; Correa 2002). This is because patents give market exclusivity for particular periods, during which time medicine prices are not subject to the downward pressures of market competition. Pharmaceutical product prices fall sharply when generic entry occurs following the expiration of patents (Scherer 2000, 1322–1324).
Global Governance for Access to Medicines Despite the scale of need for medicines in developing countries, the response of international organisations and government has been inadequate and weak. To some extent this is due to the legally entrenched privileges of pharmaceutical companies under the World Trade Organization’s (WTO) Agreement on Trade-Related Aspects of Intellectual Property (TRIPS). The TRIPS Agreement requires 20-year patents for pharmaceuticals, which give exclusive rights to prevent non-consensual use, subject to extensive domestic and international enforcement including at the WTO’s dispute settlement mechanism. It does provide exceptions to patenting and limitations on exclusivity in the interests of public health and social welfare, including parallel imports and compulsory licensing. Compulsory licensing, for example, allows governments to manufacture generic versions of patented medicines without corporate consent in certain circumstances, including for government use, in national emergency, or as a remedy for anti-competitive practice, or whenever a voluntary licence has been refused. These are, however, highly conditional grants, and licensees must pay adequate remuneration and production must be predominantly for the supply of the domestic market. This last condition effectively meant that poor countries that could not manufacture their own drugs could not access generic versions of patented medicines. It was later amended to permit, under strict conditions, least developed and other developing countries to import generics made under compulsory licensing. While measures such as compulsory licensing were included in the TRIPS Agreement to preserve a balance between private proprietary interests and public health needs, in practice their use has been tremendously contested by corporate litigation and governmental trade sanctions. In response, developing countries pushed for a confirmation of the legality of TRIPS flexibilities including compulsory licensing in the 2001 Declaration on the TRIPS Agreement and Public Health (WTO 2001, paras. 4 and 5). Despite the declaration, countries that attempt to use compulsory licensing remain subject to corporate litigation and unilateral trade sanctions. For example, in 2002, the U.S. government pressured Korea to refuse a compulsory license for Gleevec, a leukemia drug that costs around US$27 000 per annum per person. In 2006 Pfizer sued a Philippine company and government officials in their private capacity to prevent parallel importing of a generic version of Norvasc, a hypertension drug (Sanjuan 2006). Most recently, in 2007, when Thailand issued compulsory licences on antiretroviral therapy (ART), this led Abbott’s Laboratories to withdraw seven essential drugs from the country, and the
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U.S. Trade Representative (USTR) placed Thailand on its Special 301 Report watch list citing ‘a weakening of respect for patents’ (Irvine 2007). At the same time, countries themselves often trade away these capabilities in the TRIPS Agreement as a precondition for accessing rich country markets, foreign aid, or investment. The most prevalent form of this push for TRIPS-plus intellectual property is in bilateral and regional free trade agreements that extend patent periods beyond 20 years, limit compulsory licensing, prohibit parallel imports, and generally make it more difficult for generic drugs to enter the market on patent expiration (Forman 2006). More than 60 countries, many of which are developing countries, are now bound by these kinds of TRIPS-plus standards. Yet until the early 2000s, enabling access to affordable medicines received little or weak attention in international efforts to address global health challenges. This is evident in the Millennium Development Goals (MDGs) devised in 2000, which include three health-related goals to reduce child mortality, to improve maternal health, and to combat HIV/AIDS, malaria, and other diseases. Access to medicines is not included as a primary goal but rather as a subsidiary target under Goal 8, which aims to develop a global partnership for development. Its inclusion is as a resolution to ‘encourage the pharmaceutical industry to make essential drugs more widely available and affordable by all who need them in developing countries’ (United Nations General Assembly 2000, para. 20). This approach is notable for its failure to identify governmental capacities to reduce drug prices through measures such as compulsory licensing and parallel importation. Certainly encouragement of the industry to reduce prices could encompass a broad range of actions, including governmental threats of compulsory licensing. Nonetheless, the soft approach of this resolution and its failure to identify the responsibilities of governments and international organisations explicitly regarding medicines access likely reflect the prevailing international opinion at the time that compulsory licensing was a highly contentious strategy of indeterminate legality and a corresponding unwillingness to invoke the considerable opposition of the pharmaceutical industry and the U.S. government. The lack of global governance on this issue came to prominent attention with the issue of AIDS medicines in developing countries. In 1996, the efficacy of ART for HIV/AIDS was revolutionised with the introduction of protease inhibitors, which, in combination with existing drugs, dramatically reduce HIV levels in the blood. The use of these therapies in Europe and North America has greatly decreased AIDSrelated deaths and almost eliminated maternal transmission of the virus, transforming HIV infection from a progressive life-threatening illness to a treatable and chronic condition. Yet concurrent with these medical advances in the West, infection rates in sub-Saharan African countries were exploding and millions of Africans were dying each year from untreated AIDS. At approximately US$15 000 a year per person, drug prices presented the primary stumbling block to broader access in sub-Saharan Africa. Given these prices, the prevailing global consensus was that it was simply not cost effective to fund AIDS treatment: even the WHO and UNAIDS argued that funds should be allocated to HIV/AIDS prevention rather than treatment (WHO and
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UNAIDS 1998, 13). As a result, there was no international funding for developing countries to purchase drugs, and companies gave extremely limited price concessions. Access to ART in developing countries generally was around 5 percent, and in subSaharan Africa—the epicentre of the global pandemic—access was considerably under 1 percent. Yet access to AIDS treatment in sub-Saharan Africa was seen not simply as financially unwise but as naive, unrealistic, and even unlawful. International organisations, pharmaceutical companies, and governments argued that the TRIPS Agreement did not permit limitations of patents; that patents could not be limited in any way without destroying the medical innovation system; that poverty, not patents and prices, determined access to medicines (International Federation of Pharmaceutical Manufacturers and Associations 2000, 10; Rozek and Berkowitz 1998); that access to medicines in poor countries was in any event irremediable; that African healthcare systems were inadequate for the complex and expensive task of monitoring the efficacy of complicated ART; and that Africans were in any event too ignorant to adhere to complicated ART routines (Donnelly 2001). A Shifting Approach to AIDS Treatment: Human Rights and the Pharmaceutical Manufacturers’ Association of South Africa Civil society actors and people with HIV/AIDS around the world were not, however, content to accept the status quo, and global treatment advocacy focussed on AIDS medicines emerged (Highleyman 2001; t’Hoen 2002). In the face of the almost unchecked growth of HIV/AIDS in sub-Saharan Africa and its corresponding mass scale of deaths, activists were able to force the question of affordable AIDS medicines into the global spotlight as a grave human rights concern, rather than simply a question of intellectual property protections under the TRIPS Agreement. While the human rights dimensions of the problem were to some extent evident in the scale of HIV/AIDS-related deaths in sub-Saharan Africa, activists were also able to point to the legal protection that international human rights law gives to the right to health and its implied right to access essential medicines (see, for example, UN Committee on Economic and Social Council Committee on Economic, Social and Cultural Rights [CESCR] 2000, art. 12.1; UN Office of the High Commission for Human Rights [UNHCHR] 1966, paras. 12 and 43). However, international human rights law offered only vague normative support for the proposition that access to medicines should supersede intellectual property protections. Ensuring that governments lowered ART prices as a human rights duty required a different consensus in global policy circles. The impetus for this shift came in the infamous case of the Pharmaceutical Manufacturers’ Association of South Africa (PMA) versus the South African government.1 Between 1997 and 2001, the U.S. and 40 pharmaceutical companies used trade pressures and litigation to prevent the South African government from passing legislation to access affordable medicines. South Africa, then as now, had one of the world’s largest HIV epidemics. The industry claimed that the legislation (and the parallel importing it authorised)
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breached the TRIPS Agreement and South Africa’s constitutional property protection. It also argued that the proposed act threatened the industry’s incentive to develop new medicines. The response of industry and the U.S. government, and the implications for access, attracted very unflattering media attention, partly generated by domestic and international protests. In 2000 the U.S. withdrew its trade pressures after Al Gore was embarrassed by AIDS advocates during his campaign for the presidency. However, the pharmaceutical companies went to court in South Africa. In April 2001 South African treatment advocates joined the government’s case, showing the weakness of corporate arguments both against the legislation’s TRIPS legality and the necessity of research and development (R&D) in opposing the legislation. South Africa’s constitutional framework considerably assisted activist claims, particularly because it entrenches a justiciable right of access to healthcare services. Using this framework, activists brought human rights arguments drawn from international and domestic law and argued that the right to health provided constitutional authority for the legislation itself and a legal interest that should be prioritized over corporate property rights. At the same time, an extraordinary level of public action accompanied the case. On the day the case began, there was an international day of action with demonstrations held in 30 cities around the world. A petition opposing the litigation signed by 250 organisations from 35 countries was published in Business Day, a national South African newspaper. Médecins Sans Frontières (MSF) initiated an international petition that collected 250 000 signatures and persuaded the European Union and the Dutch government to pass resolutions calling for the case to be dropped, followed by the German and French governments (McGreal 2001). The WHO not only stated its support for South Africa’s defence of the litigation but also provided legal assistance (de la Vaissière 2001), and in the days before the hearing, Nelson Mandela, the former South African president, received considerable media attention for criticising the pharmaceutical companies for charging exorbitant prices on AIDS drugs (Denny 2001). This confluence of activism attracted an extraordinary amount of global censure against the corporations, which recognised that they had far more to lose through reputational damage than anything the legislation in question could possibly lead to. In April 2001, the pharmaceutical companies withdrew their case. A Changing Environment for AIDS Medicines The PMA case precipitated a discernable shift in the way that governments, pharmaceutical companies, and international organisations addressed the question of AIDS treatment in Africa. The first outcome was a sharp upsurge at the United Nations in international statements on treatment as a human right and articulations of state obligations to provide ART (see, for example, UN Economic and Social Council Commission on Human Rights 2001c; 2001b; 2001a; 2002; 2003; CESCR 2001; UNHCHR 2006; Office of the High Commissioner for Human Rights 2004; UNAIDS 2002). This process moved later that year to the WTO (2001) in the Declaration on the TRIPS Agreement and Public Health, which articulated the use
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of measures such as compulsory licensing as a ‘right’ of governments in protecting public health and promoting access to medicines. These rhetorical commitments were matched by considerable policy and price shifts. As a combination of pressure, concessions, and generic alternatives from India, which was not yet bound by the TRIPS Agreement, drug prices in many low income countries dropped from US$15 000 to as low as US$148 per annum per person (WHO and UNAIDS 2006, 20). Global funding mechanisms were created, such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), and the World Bank’s Multi-Country HIV/AIDS Program for Africa. These have become primary sources of financial assistance for treatment programmes in developing countries, especially in subSaharan Africa. After doing very little about access to ART in the developing world, in July 2002 the WHO (2004a) announced the adoption of the ‘3 by 5’ initiative, an ambitious and essentially advocacy-oriented programme designed to place 3 million people in developing countries on ART by 2005 through providing extensive technical assistance and guidelines to countries. The WHO explicitly intended the adoption of this programme to be the realisation of human rights. While this goal of bringing ART to 3 million people was not achieved, by 2005 more than 1 million people in developing countries were receiving treatment. The WHO thereafter shifted upward to the goal of achieving universal access to ART by 2010 for all those who need it. This commitment was similarly made by governments participating at the 2005 UN World Summit (UN General Assembly 2005, para. 57[d]) and adopted that same month by the G8 (2005, para. 18[d]) at the Gleneagles G8 Summit as a programmatic aspiration for assistance to Africa. Access to ART in sub-Saharan Africa rose from less than 1 percent in 2000 to 28 percent in 2007 (WHO, UNAIDS, and UNICEF 2007).
Human Rights as a Framework for Global Governance The AIDS medicines experience holds a number of implications for global health governance. Its outcomes indicate that rights-based discourse, litigation, and action played significant roles in shifting policy, prices, and perception regarding AIDS medicines. In the PMA case, activists were able to use rights-based arguments in concert with mass action and media attention to ensure a growing reputational damage for the industry, which ultimately assured their withdrawal of the litigation. However, the PMA case also illustrates how social action and rights discourse persuaded a global collective of the legitimacy of the rights claim for medicines, and of the immorality of the corporate positions. This not only assured the collective disapproval that became so important to ensuring the corporate withdrawal of its litigation, but also ensured a far broader global acceptance of the rights claim and a shift in perspectives on the moral necessity of AIDS medicines in Africa. The impact of rights-based social action therefore appears to have shifted the global
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consensus toward enabling access to AIDS medicines in Africa and to have produced corresponding changes amongst primary global health actors. These outcomes discount the suggestion by Andrew F. Cooper, John J. Kirton, and Ted Schrecker (2007, 231) that the human rights claim for health ‘has little appeal beyond the human rights community’. Yet broad-based effects from human rights claims are not unique to the AIDS medicines experience. The normative shifts achieved in the past century with regard to slavery, women’s right to vote, colonialism, and apartheid have first and foremost been a product of rights-based social movements. Human rights have been central to these outcomes, providing important counterpoints to arguments based on utility, commerce, or security that have sustained grossly unjust systems such as slavery or apartheid. Indeed, there is an emerging broad recognition that social movements have been critical actors in the production of many of the human rights norms and legal protections now entrenched in international human rights law (Rajagopal 2003a, 2003b; Baxi 2002; Santos 2002; Risse-Kappen 1995). Thus rather than simply being western gambits imposed on an unwilling global South, evidence suggests that human rights oftentimes emerge from subaltern legal and political struggles that hold a ‘creationist’ and ‘jurisgenerative’ potential (Baxi 2002, 101; Siegel 2004). This bottom-up process suggests strategic opportunities for advancing the normative frameworks on which global health governance could rest. This is not to overlook or downplay the practical and theoretical limitations of international human rights law or the right to health. International human rights law remains plagued by gross inefficacies and neglect, animated most grievously by the persistence not only of genocide but of global failures to intervene in ongoing slaughter in Rwanda and Darfur. Moreover, the universality of international human rights law is often disputed given its liberal roots and its apparent irrelevance in various parts of the world such as China. Similarly, as Colleen O’Manique (2007) points out, claims of universality must also contend with considerable variations and historical contingencies in domestic understandings of and responses to rights. These arguments undeniably hold elements of truth. However, they cannot and do not negate the strong evidence that illustrates the potential power of rights. To some extent this power emerges from rights and law in general, which can be wielded either as a regulating force to sustain the status quo or an emancipatory force for social transformation (Santos 2002, 2–3). Nonetheless, human rights, distinct from rights and law of any nature, hold an explicitly transformative potential given their focus on achieving equal worth and dignity for all people. Moreover, while the genesis of international human rights law may have drawn from a strongly liberal U.S. rights culture, its inclusion of social and economic rights suggests that this body of law cannot be accurately characterised as exclusively liberal in nature. Indeed, these rights can be seen as offering an important corrective to the liberal emphasis on private property and individual freedoms and its consequent tendency to entrench existing inequalities (Otto 1997, 7). In any event, human rights cannot be categorised simply as liberal imprimaturs: as Dinah Shelton (2007, 1) amply illustrates, they hold antecedents in millennia of cultural, religious, ethical,
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and legal concerns shared across diverse cultures. Moreover, there is every indication that whatever their origins, human rights are becoming rooted in diverse jurisdictions globally, some of which are producing alternative rights cultures more attentive to structural inequalities, basic socioeconomic needs, and collective duties. This is most apparent in the emergence from South Africa of a communitarian conception of human rights based on African notions of ubuntu (Forman 2008), and a strong Latin American conception of rights that has ‘synthesized the individualistic with the social and economic dimensions of human dignity’ (Carrozza 2003, 312). Academic debates over the limited efficacy of international human rights law must also contend with the growing legal enforcement of the right to health. South Africa is at the forefront of these changes, with a post-apartheid constitutional healthcare right, which social actors have effectively enforced against governments and corporations alike in accessing AIDS medicines.2 However, these trends are replicated in jurisdictions across the globe: in Thailand in 2002, nongovernmental organisations (NGOs) used constitutional and international human rights to health and life to challenge a Bristol Myers-Squibb patent on an antiretroviral drug. The court partially invalidated this patent to permit domestic production and distribution of a generic version of this medicine, holding that ‘medicine is essential for human life’ and that ‘the treatment of life and health transcends the importance of any other property’.3 In Latin America, a study reported that courts throughout the region have enforced human rights in international, regional, and national laws to require government provision of AIDS medicines (Hogerzeil et al. 2006). The consistent variables in countries where there was successful litigation were ratification of the Covenant on Economic, Social, and Cultural Rights and the entrenchment of constitutional rights to health (306). In this regard it is notable that 153 countries (two thirds of the global total) are parties to the covenant, and that 192 countries (every country in the world except the U.S. and Somalia) are parties to the Convention on the Rights of the Child, which also includes a right to health (UNHCHR 2006). There is similarly high domestic protection of this right, with almost two thirds of all national constitutions now including health and health-related rights (Kinney and Clark 2004, 287). The right to health is therefore increasingly legally binding in diverse jurisdictions and being effectively deployed to ensure access to health care and medicines. Certainly human rights do not hold this legal force in all countries. Yet while human rights may hold little or no legal status in non-democratic or autocratic regimes such as China and Myanmar, it is equally apparent that the power of human rights is not determined solely by legal factors. In the 60 years of their existence as international law, human rights have assumed a considerable moral and normative force, becoming seen as the ‘dominant moral vocabulary of our time’ (Gready 2003, 749) and the only political-moral idea that has received universal acceptance (Henkin 1990, xvii). While this provides no assurance of governmental compliance with human rights, human rights are increasingly claimed as a language of social justice by social movements around the world. Indeed, emerging evidence suggests that the use of human rights strategies in combination with social action
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has achieved changes in domestic governance across a ‘strikingly different range of regions, countries, socio-economic systems, cultures, and types of political regimes’ (Risse and Ropp 1999, 238). The efficacy of human rights–based advocacy in nondemocratic and non-human rights societies can be seen to disconfirm the notion that ‘international human rights are fundamentally alien to particular cultures or regions of the world’ (239). Thus far from being imposed on developing countries from the top down as part of a western ‘civilising mission’, human rights are also being claimed from the bottom up by ‘subaltern’ actors themselves. Not only do these social claims add to the growing efficacy of human rights, but these dialogic processes may also ground rights in diverse domestic contexts, realise them, and ensure their cross-cultural application. International human rights law therefore offers global health governance a normative framework rooted in moral consensus and reflected in the coercive and strongly persuasive mechanisms of law. This is not to suggest that human rights should crowd out alternative ethical frameworks for global health governance. Instead, rights should be seen as an important complement to other projects concerned with achieving global health equity, such as public health ethics (see, for example, Benatar, Daar, and Singer 2003). Indeed, integrating human rights with other ethical approaches to global health may overcome some of the more fundamental limitations of rights and rights strategies. To some extent, these limitations are reflected in the greatly amplified yet persistently limited access to AIDS medicines in developing countries. Indeed, at 28 percent, two thirds of people in need remain without access. This limited access suggests the broader limitations of the stimulus-response-innovation model identified by Cooper, Kirton, and Schrecker, where social actors only innovate in response to the demands arising from severe shocks or crises. The limited success of reactive strategies is similarly identified by Kimberly Crenshaw (2000, 72), who argues that if rights strategies simply point to contradictions between dominant ideology and certain material realities, they run the risk of adjusting circumstances only to the extent necessary to close the contradiction. This outcome is evident to some extent in the fact that the activists have only been able to achieve a limited carve-out for using compulsory licensing or other TRIPS-compliant flexibilities in relation to AIDS medicines in Africa. As persistent litigation and trade sanctions against Thailand’s compulsory licensing of medicines suggests, other health needs in other jurisdictions are still not seen as adequately entitling this action. These outcomes suggest that transcending the limitations of existing strategic approaches requires more systemic and less reactive solutions to problems such as medicines access. International human rights law offers a normative framework within which to explore such systemic solutions to global health challenges. Human rights offer a practical and normative tool for increasing the priority that the human rights and public health needs of the global poor receive in general, and particularly when these are deemed to conflict with free trade and commercial interests. The AIDS medicines experience suggests the potential of rights and social movements to make
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some headway in achieving this goal. However, as James Orbinski (2007) suggests, rights achieved must be defended and constant vigilance is required to maintain hard-won gains. Ensuring that human rights influence political practices regarding medicines and their underlying normative foundations requires consistent and persistent advocacy toward an alternative normative framework for global health governance.
Notes 1 Pharmaceutical Manufacturers’ Association and Others v. The President of the Republic of South Africa. Case no. 4183/98, Trans. Prov. Div. 2 Minister of Health and Another v. Treatment Action Campaign and Others (2002) 5 South African Law Report 721 (South African Constitutional Court); Hazel Tau & Others v. GlaxoSmithKline and Boehringer Ingelheim, Competition Commission of South Africa, 2002. More generally, see Forman (2007). 3 AIDS Access Foundation et al. v. Bristol Myers-Squibb Company and Department of Intellectual Property (2002), Central Intellectual Property and International Trade Court, Black Case No. Tor Por 34/2544, Red Case No. 92/2545.
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World Health Organization and UNAIDS (1998). Guidance Modules on Antiretroviral Treatments: Module 9, Ethical and Societal Issues Relating to Antiretroviral Treatments. WHO/ASD/98.1 and UNAIDS/98.7. World Health Organization and UNAIDS (2006). Progress on Global Access to HIV Antiretroviral Therapy: A Report on ‘3 by 5’ and Beyond. March. <www.who.int/hiv/ fullreport_en_highres.pdf> (September 2008). World Health Organization, UNAIDS, and UNICEF (2007). Towards Universal Access: Scaling Up Priority HIV/AIDS Interventions in the Health Sector. Progess Report, April. <www.who.int/entity/hiv/mediacentre/universal_access_progress_report_en.pdf> (September 2008). World Trade Organization (2001). ‘Declaration on the TRIPS Agreement and Public Health.’ WT/MIN(01)/DEC/2. 14 November. <www.wto.org/English/thewto_e/minist_e/min01_e/ mindecl_trips_e.htm> (September 2008).
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Part V Conducting Campaigns against Chronic Illness: Polio and Tobacco
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Chapter 11
Rotary International and Eradicating Polio Robert Scott, Wilfrid Wilkinson, and John Eberhard
While once it might seem impossible to imagine a world where all children can run free, where none has the risk of picking up the crippling infectious poliomyelitis virus, today such a situation is almost a reality. Certainly, this is the case in North America, Europe, and Latin America, and could soon be so in Africa and South Asia. Yet as recently as two decades ago there were an estimated 350 000 cases of polio and it was endemic to 125 countries. It is through regional and global campaigns involving governments, international health organisations, development agencies and nongovernmental organisations (NGOs) that a 99 percent global reduction of polio cases has become a reality. The route to this grand achievement is a story of perseverance on all fronts: the medical science field, the affected children and their communities, health practitioners and volunteers, and international political actors. Even with a vaccine, however, the success of the global eradication campaign depended very much heavily on extensive resource mobilisation and management as well as political will. Rotary International, an NGO with a network of service clubs with more than 1.2 million business, professional, and community leaders in 200 countries and geographical regions around the world, significantly assisted in this process. It made a mark as one of the few NGOs that contributes funds to the United Nations system and international projects, in some cases closely matching the donations of national governments.1 In establishing its PolioPlus initiative in 1985, Rotary became a key collaborator and a beacon in taking on the challenge of polio eradication globally. Such activity was essential to achieving some of the best international coordination efforts seen to date for implementing child vaccination programmes and development assistance and demonstrating the power of people, community organisations, and goodwill in overcoming global challenges such as disease. The global eradication of polio has not been an easy assignment to undertake, for Rotary International or for any other global actor. For one, certain circumstances had to fall into place, such as the development of an effective and easily distributable vaccine. Numerous partners and groups had to be brought on board, which required a strong sense of timing and the ability to take opportunities as they presented themselves. Also, maintaining a prolonged operational effort to ensure global reach and a sustainable project is taxing, as is the daunting task of advocacy to mobilise
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political forces to ensure appropriate funds and action throughout a campaign that has lasted more than 20 years. That Rotary International has been able to sustain its high levels of performance is a testament to the strengths of including such an organisation in global initiatives. It certainly raises the question of what these specific capabilities are and how to leverage them further.
The Rotary PolioPlus Programme Since 1985, Rotary’s (2008a) PolioPlus programme has raised funds and contributed volunteer time and networking expertise to eradicate polio. To date more than 2 billion children worldwide have been immunised (International PolioPlus Committee 2008). In 2007, the Bill and Melinda Gates Foundation contributed US$100 million to the programme, which Rotary committed to match so that it will have raised a total of more than US$800 million (Hearn and Nixon 2007). These Rotary contributions not only signify dollars but also represent the development of an effective system of delivery, social mobilisation, and thinking through the problems that appeared along the way of the campaign. Rotary International’s involvement with polio began in 1979, when it put forth a five-year plan to deliver the polio vaccine to 5 million children in the Philippines through its local clubs. Shortly thereafter, this project, under the Rotary Health, Hunger, and Humanity Program, was expanded to include Haiti, Bolivia, Morocco, Sierra Leone, and Cambodia (Grand Prairie Metro Rotary Club 2005). This activity was happening alongside the launch in 1974 of the World Health Organization’s (WHO) Expanded Programme on Immunization (EPI) to combat measles, diphtheria, pertussis, tetanus, tuberculosis, and polio. As well, in 1979 the world was declared free of smallpox, the first disease to be eradicated by humankind. Thus, there was much action, enthusiasm, and hopefulness for being able to achieve a large-scale polio eradication programme. In 1985, Rotary put in place its PolioPlus campaign, which included a US$120 million pledge to purchase vaccine. Within three years the amount actually raised had risen to US$247 million (Grand Prairie Metro Rotary Club 2005). This ambitious commitment was a significant catalyst for the global public health community to make global eradication possible. The major partners to this programme became the WHO, the United Nations Children’s Fund (UNICEF), and the U.S. Centers for Disease Control and Prevention (CDC).
The Beginnings of Polio Eradication The fight against polio was most prevalent at first in North America. Prominent actors such as the Rockefeller Foundation and President Franklin D. Roosevelt, himself crippled by the disease, had invested time and money on alleviating the effects of this disease in the 1930s. Significant advances in scientific research and vaccine
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development for polio came through in the U.S. during the 1950s. Of note, the incidence of polio was much greater in the industrialised countries throughout the 19th and early 20th centuries. By 1961 two vaccines had been approved for use in the U.S. (Hellman 2001). First Jonas Salk developed an inactivated polio vaccine (IPV) administered by injection from a killed version of the virus in 1952. More than 300 million doses were administered in the U.S. between 1955 and 1961, resulting in a 90 percent decrease in incidence (de Quadros et al. 1992, 239). Then, in 1961, Albert Sabin introduced an oral polio vaccine (OPV) from a weakened version of the virus. Because it is administered by mouth, the OPV was more effective in halting the person-to-person transmission and, at approximately 5 cents per dose, it ‘was far easier and cheaper to use, a major factor in large parts of the world’ (Hellman 2001, 138–139). Thus this vaccine became the standard as the immunisation process began across the globe. The first major region outside North America to focus on eliminating the polio virus was Latin America and the Caribbean, where the OPV was introduced via the EPI in 1977. Until the 1980s, of all the vaccines administered through the EPI, OPV coverage there was the widest and led to a significant decrease in polio cases. This encouraged the Pan American Health Organization (PAHO) ‘to propose the eradication of indigenous wild poliovirus in Latin America and the Caribbean by 1990 through a coordinated regional effort’ (Levine 2005, 41). PAHO passed a resolution in 1985 and thus launched a programme to eliminate polio from the region. This initiative had many positive starting blocks to support its success. Key actors were involved such as PAHO, UNICEF, the U.S. Agency for International Development (USAID), the Inter-American Development Bank (IDB), the Canadian Public Health Agency, and Rotary International. The endemic countries were willing and able to contribute much of the funds needed, typically 70 percent at first, later increasing to 80 percent. A positive experience with the EPI was helpful. Moreover, the vaccine was inexpensive, readily available, and easily administrable. Although the campaign was well placed to take on the significant challenges that accompany a large-scale initiative to eradicate a disease, many obstacles to reaching remote populations and addressing the particular characteristics of the virus were unavoidable. It takes a country three years from the date of the last case of polio to be certified free of polio. Given of the nature of the disease, if a single case manifests itself, the entire community is likely affected because symptoms only show up in 1 percent of those infected. Thus, for eradication to become a reality, the strategy had to be very methodological and well planned in order to achieve and maintain a high level of vaccination coverage (de Quadros 1997). A cold chain for the delivery of the vaccine was established. National immunisation days (NIDs) were held to boost regular vaccinations and maximise coverage. Surveillance efforts included setting up a network of diagnostic laboratories and reporting clinics in the endemic countries to identify and test for new cases quickly. The training of local populations in all these aspects of the programme was indispensable to ensure the largest success. In all these cases Rotary International either contributed the necessary funds and resources, brought in the human resources, or rounded up experts to overcome
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obstacles. Through its membership, Rotary International was able to launch an army of willing and able persons: members are organised into community clubs, each of which took on specific tasks and thus became skilful in executing them. As local business and professional leaders, who are highly motivated and resourceful, many members brought specific related expertise, in fields such as medicine and engineering. As community and national leaders, Rotarians can help overcome local or national political and bureaucratic problems as they arise. In this regard, Rotary International essentially became a ready-to-go effective management team able to deploy personnel as needed.
The Global Polio Eradication Campaign As the eradication of polio in Latin America and the Caribbean was moving at an encouraging pace, it was a suitable template for expanding the campaign (de Quadros 1997, 128). In 1988, the World Health Assembly (WHA) set the goal of eradicating polio world-wide by 2000. Rotary International was to play an essential role; in fact, a portion of the funds it had raised had been directed to support a group of experts on polio at the WHO to guide the global programme (Beigbeder 1997). The western Pacific region became the initial focus for the global campaign. China had initiated its own biannual NIDs in 1993 with success similar to Latin America’s. Following this example, most countries implemented the polio eradication strategy, with India and 16 African countries beginning their NIDs in 1996. The most difficult areas to reach have been countries in the midst of conflict. The polio campaign adapted to such circumstances, however, and worked to negotiate ‘Days of Tranquillity’, during which arms would be laid down in a cease-fire agreement so that children caught behind the lines of combat could be immunised. Such initiatives are needed more than ever in Afghanistan and some western African countries. The goals of eradication of 1990 for Latin America and the Caribbean and of 2000 for the world have been useful even though they were not entirely met. The region of Latin America and the Caribbean was certified polio free in 1994, after the last case was reported in 1991. The western Pacific was certified in 2000 and Europe in 2002. Globally, there were 1315 cases in 2007 (Global Polio Eradication Initiative 2008a). Nigeria, India, Pakistan, and Afghanistan are still endemic countries while Angola, Nepal, Chad, Eritrea, the Democratic Republic of the Congo, West Africa, and the Horn of Africa have reported imported cases. To achieve its polio-free status, the Latin America and Caribbean campaign implemented Operation Mop Up to tackle the lingering incidences. There were only seven cases left in 1991 (six in Colombia and one in Peru). The aggressive campaign consisted of house-to-house visits to reach 1 million households. Such a labourintensive process was possible through the coordination and cooperation of Rotary and the other spearheading partners. Today, similar efforts with two improved vaccines are under way to reach the last strong holds of this virus around the world (Global Polio Eradication Initiative 2005).
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The Advocacy Component To attain such success, not only must the operations and implementation strategy be sound, but a strong advocacy arm is also necessary. Advocacy is the tool to raise awareness among leaders and powerful groups, prevent complacency and resurgence of the virus, to reach countries in conflict, and to bring forth large-scale funding. Rotary International has been highly involved in this aspect of the global polio eradication campaign. Through PolioPlus, Rotary began its advocacy activities in 1995 to encourage governments to put funds toward the cause. In 2001, the Polio Advocacy Group (PAG) was formed with representatives from Rotary International, the WHO, UNICEF, and the United Nations Foundation. The PAG was to raise resources with the objective of targeting governments and non-profit organisations to contribute to the polio campaign. By 2005, these advocacy efforts had raised US$1.5 billion (Grand Prairie Metro Rotary Club 2005). To back up these calls for funds, Rotarians themselves have committed wherever and whenever necessary. To meet the needs of the eradication process, an emergency fundraising campaign for polio through local Rotary clubs and the Rotary Foundation was launched in 2002, with a goal of US$80 million one year. The total actually raised, through the clubs, the foundation’s matching mechanism, and government matching grants, reached US$135 million (Rotary International 2006). Showing the power and global scope of the Rotary network of community clubs, contributions were received from all the 529 Rotary districts, with contributions from 22 645 clubs in 153 countries. Rotary’s specific advocacy activities have also been widespread and powerful. It has national advocacy advisors in 23 donor countries to solicit political and financial support from these governments. They also have national PolioPlus committee chairs in 32 endemic or high-risk countries to maintain political commitment from their governments. Individual Rotarians have worked to secure commitments from multilateral groups such as the G8, member countries of the Organisation for Economic Co-operation and Development (OECD), the African Union (AU), and the Organisation of the Islamic Conference (OIC). The ability of Rotary members to set up and partake in such initiatives demonstrates the strength in having an organisation that can leverage local leaders into coordinated global action. Such activities and a networked presence have been a major boost to the global polio eradication campaign.
The Power of the Local in the Global For most of its history, Rotary International has had a presence in international affairs, by the very nature of the local clubs taking on international projects. Thus its interest in the global challenge of polio was not unusual; however, its ability and resilience to sustain such a tremendous effort were tested through the global eradication
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campaign. The structure of the organisation and the quality of its membership have played a significant role in allowing this to be the case. The first official Rotary club began in Chicago in 1905. In 1910 Rotary moved outside the U.S. with a club in Winnipeg, and became Rotary International. By 1922 the concept of the community service club had spread across six continents. The Rotary Foundation was established in 1917 to build upon the enthusiasm of these community leaders to provide ‘service above self’ and do good in the world. The foundation’s initial project was to encourage cultural exchanges through graduate fellowships. Today it promotes a multitude of humanitarian programmes, ranging from Preserve Planet Earth, a programme that since 1990 has addressed illiteracy, drug abuse, and the needs of both an aging population and the increasing number of children at risk. Rotary has a strong affinity with the United Nations. There were 49 Rotary members serving in 29 delegations to the UN at the charter conference in 1945 (Rotary International 2008b). Throughout the years the organisation has consistently maintained its support for the UN in sending observers conferences, staffing a New York office at the UN and in Geneva, and promoting the UN by having representatives on 14 different UN agencies including the World Bank. This history of international experience is an important piece of Rotary International’s ability to interact with other global actors and mobilise its local clubs to act on global issues. From the bottom-up perspective, Rotary’s organisation is set up to encourage the local clubs to take initiative. This permits the international NGO to be light and flexible while still maintaining a large base of members that can be activated to take on a global campaign. In having a network of independent local clubs, Rotary International encourages experienced business and professional leaders to drive projects that are relevant and meaningful to the membership. Because the membership of a local club consists of various professions, the skill set, expertise, and influence available in each group provide a very effective team to take on a numerous set of challenges. Additionally, the Rotary Foundation, which matches grants, allows an individual club to expand a project with support from the larger organisation should it meet set criteria.
Rotary Next Steps The primary focus of Rotary International remains the achieving of polio eradication across the world. The success of such a lofty goal is incredibly close but requires continued dedication to assist in the management of the campaign as well as continue its advocacy and community mobilisation. The achievements to date and the extensive contributions in time and money cannot slip away. None of the world is secure until the interruption of the transmission of the wild polio virus is certified. Until then, polio remains just an airplane ride away from any place in the world. By the organisation’s centennial in 2005, at the 20-year mark of the campaign to eradicate polio, Rotary International had experienced some fatigue. Beating a
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virus is not an easy task and can be unpredictable. Nonetheless, Rotary International and its spearheading partners have shown they are capable to go to great lengths. Only 32 new cases were identified in Pakistan in 2007 (Global Polio Eradication Initiative 2008a). Nigeria and India, which has been reinfected after dipping down to only 66 new cases in 2005, remain the greatest threats with just 575 and 359 cases respectively in 2007 (Global Polio Eradication Initiative 2008b). With a successful end to the campaign in sight, Rotary International is poised to take on a new global challenge and there is a long list from which to choose. The PolioPlus programme is a shining example of what to expect from such an organisation. The decision of where to focus next draws heavily from the expertise gained and lessons learned throughout the polio campaign. Whatever it may be, certainly Rotary’s capacity to implement operational strategies world-wide, to cooperate with a multitude of partners, and to establish an effective advocacy arm will be excellent tools indeed.
Note 1 For a description of the history of Rotary’s involvement and a comparison to other NGO efforts, see Beigbeder (1997).
References Beigbeder, Yves (1997). ‘Another Role for an NGO: Financing a WHO Programme—Rotary International and the Eradication of Poliomyelitis.’ Transnational Associations, vol. 49, no. 1, pp. 37–43. <www.globalpolicy.org/ngos/ngo-un/rest-un/2000/1204.htm> (September 2008). de Quadros, Ciro A. (1997). ‘Global Eradication of Poliomyelitis.’ International Journal of Infectious Diseases, vol. 1, no. 3, pp. 125–129. de Quadros, Ciro A., Jon K. Andrus, Jean-Marc Olive, et al. (1992). ‘Polio Eradication from the Western Hemisphere.’ Annual Review of Public Health, vol. 13, pp. 239–252. Global Polio Eradication Initiative (2005). Polio News. Issue 25. <www.polioeradication.org/ content/polionews/PolioNews25.pdf> (September 2008). Global Polio Eradication Initiative (2008a). ‘Wild Poliovirus Weekly Update.’ 20 August. <www.polioeradication.org/casecount.asp> (August 2008). Global Polio Eradication Initiative (2008b). ‘Wild Poliovirus 2000–2008.’ 20 August. <www. polioeradication.org/content/general/casecount.pdf> (August 2008). Grand Prairie Metro Rotary Club (2005). ‘History of PolioPlus.’ <www.gpmrotary.com/ polioplushistory.php> (September 2008). Hearn, William and Dan Nixon (2007). ‘RI, Gates Foundation Commit US$200 Million.’ 26 November. Rotary International. <www.rotary.org/en/mediaandnews/news/pages/ 071120_news_gannounce.aspx> (September 2008). Hellman, Hal (2001). Great Feuds in Medicine: Ten of the Liveliest Disputes Ever. (Toronto: John Wiley and Sons).
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International PolioPlus Committee (2008). ‘Statements on Current Facts and Figures Relative to Polio Eradication and the Role of Rotary International in the Global Effort.’ Rotary International. <www.rotary.org/RIdocuments/en_pdf/polio_facts.pdf> (September 2008). Levine, Ruth (2005). Millions Saved: Proven Success in Global Health. (Washington DC: Peterson Institute for International Economics). Rotary International (2006). ‘PEFC Contributions Top US$135 million.’ Rotary World, January, p. 6. <www.rotary5220.org/Common/Rotary-World/rw_0601_en.pdf> (September 2008). Rotary International (2008a). ‘A Brief History of PolioPlus.’ <www.rotary.org/en/ ServiceAndFellowship/Polio/RotarysWork/Pages/WhatRotaryisdoing.aspx> (September 2008). Rotary International (2008b). ‘History.’ <www.rotary.org/en/aboutus/RotaryInternational/ history/Pages/ridefault.aspx> (September 2008).
Chapter 12
Globalisation and the Politics of Health Governance: The Framework Convention on Tobacco Control Jeff Collin and Kelley Lee
Unanimous endorsement by the 56th World Health Assembly (WHA) in 2003 signalled the successful conclusion of four years of negotiations for the World Health Organization’s (WHO) Framework Convention on Tobacco Control (FCTC). Comprising two preliminary meetings of a working group and six sessions of an intergovernmental negotiating body (INB), these negotiations constituted the WHO’s first attempt to exercise its constitutional authority to develop a global public health treaty (Shibuya et al. 2003). Although lacking in binding obligations, the agreed text incorporates a wide array of measures and represents a reasonable approximation of current best practice in tobacco control. Among key features are provisions encouraging parties to the convention to • enact comprehensive bans on tobacco advertising, promotion, and sponsorship; • require large, rotating health warnings on packaging, to cover at least 30 percent of principal display areas, and with provision for pictorial warnings; • prohibit the use of misleading descriptors such as ‘light’ or ‘mild’; • increase taxation of tobacco products; • provide greater protection from involuntary exposure to tobacco smoke; and • develop measures to combat smuggling (Hammond and Assunta 2003). While clearly a remarkable development within the field of tobacco control, the FCTC assumes broader significance as a striking innovation in health governance. Importantly, it constitutes an attempt to develop an appropriate response to globalisation, recognising the inability of traditional national and international governance to counter the health impacts of transnational tobacco companies effectively. This chapter begins with an account of the initiation of the FCTC process, situating its development within the context of the broader challenges confronting the WHO in the mid 1990s. It then examines core features of the negotiations, focussing on the role of the World Bank, the participation of member states, and the contribution
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of civil society. Tobacco industry efforts to undermine the negotiations are addressed in an analysis of internal corporate documents released following litigation in the United States. The FCTC is then discussed as an important context within which to consider the interaction among policy communities, before concluding with an assessment of its achievements and prospects.
Toward the FCTC: The WHO and Reform While the idea for a treaty to combat the rising tobacco epidemic emerged within the international tobacco control movement, the subsequent development of the FCTC needs to be explained with reference to the broader politics of health governance within the WHO in the late 1990s. The origins of the convention are usually traced back to academic lawyer Allyn Taylor’s interest in the WHO’s unexercised constitutional authority to develop international health law, ideas subsequently applied to tobacco control at the prompting of Ruth Roemer in 1993 (Mackay 2003; Roemer, Taylor, and Lariviere 2005). As key advocates sought to promote the concept within the WHO and the United Nations Conference on Trade and Development (UNCTAD), which at the time was the UN focal point for tobacco issues, it received important civil society support via a resolution of the ninth World Conference on Tobacco or Health in Paris in 1994. The formal start of the process that led to the FCTC is represented by the WHA resolution passed in May 1995 (WHO 1995). In establishing an international strategy for tobacco control, it requested a report ‘on the feasibility of developing an international instrument such as guidelines, a declaration, or an international convention on tobacco control to be adopted by the United Nations, taking into account existing trade and other conventions and treaties’. The emergence of the FCTC as a viable process backed up by substantial political commitment was not, however, evident until the 1998 arrival of Gro Harlem Brundtland, a former minister of health and prime minister in Norway, as director general of the WHO. Although one recent history of the organisation cites the FCTC as an example of an initiative credited to Brundtland that had actually begun under her predecessor Hiroshi Nakajima (Brown, Cueto, and Fee 2006), her individual significance to its development is beyond dispute. Previously the treaty proposal had met with substantial resistance among WHO officials and had lacked both political support and policy direction (Roemer, Taylor, and Lariviere 2005); now it was rapidly established as a primary objective under Brundtland. Tobacco control was announced as one of two priorities alongside malaria, and the new Tobacco Free Initiative headed by Derek Yach was accorded the status of a cabinet project and charged with the task of developing a treaty. The tobacco industry was also quick to acknowledge the significance of Brundtland’s leadership, with one document from 1999 noting that her arrival had ‘completely changed the pace and more importantly, the way of conducting the initiative’ by emphasising a rapid WHO-led process to be completed by 2003 (International Tobacco Growers Association [ITGA] 1999).
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The FCTC in core respects embodies Brundtland’s broader strategy for countering the crises confronting the WHO. The very ambition of the organisation’s first exercise of its constitutional authority to negotiate an international public health treaty demarcated the new regime from the sclerotic bureaucracy and cronyism characteristic of the Nakajima era (Yamey 2002a, 2002b, 2002c; Godlee 1994). It was by no means certain that the WHO would assume the lead role in developing a tobacco treaty, and indeed the insistence of Taylor and Roemer that it should be developed under the aegis of the WHO had previously attracted strong opposition among WHO officials (Roemer, Taylor, and Lariviere 2005). The assertion of WHO leadership among UN organisations was to be a key feature of the FCTC process, with the previous UN focal point for tobacco hosted by UNCTAD being replaced by a UN task force on tobacco control. The significance of this shift was not lost on the tobacco industry, which launched an urgent call for action from the International Tobacco Growers Association (1999) demanding that if ‘Mrs. Brundtland wants to have an all-embracing convention on tobacco control’ then its preparation should be returned to ‘the United Nations’ Focal Point to secure the participation of all sectors and all United Nations Organizations related to the theme’. The FCTC initiative was central to Brundtland’s core objective of re-establishing the status and credibility of the WHO, seeking to reposition the organisation as a ‘department of consequence’ (Kickbusch 2000). Such a restoration of the WHO’s significance depended on a broader demonstration of the political salience of global health, and Brundtland aimed to move health issues beyond the typically isolated and low-ranking health ministries: ‘I needed to move the global health agenda much more closely to the development debate, on to the tables of prime ministers and development and finance ministers, not just health ministers’ (Bruntland, quoted in Yamey 2002c). The sheer breadth of policy issues considered during the FCTC negotiations required that member states adopt a multi-sectoral perspective, given their implications for ministries such as trade, foreign policy, finance, taxation, customs, and development, in addition to health. The WHO’s advocacy for the proposed convention was also marked by attempts to situate tobacco control within broader policy agendas including gender, human rights, and development. A four-day conference on tobacco and women in Japan in 1999 culminated in the Kobe declaration, which asserted that ‘gender equality in society must be an integral part of tobacco control strategies’ (WHO 1999b); collaboration with United Nations International Children’s Fund (UNICEF) resulted in the publication of a report entitled Tobacco and the Rights of the Child (WHO 2001); while success in securing the support of the World Bank (discussed below) was of critical importance to the process. Developing a visible response to the health risks associated with globalisation was central to the broader effort to demonstrate the ongoing significance and relevance of the WHO, and again the FCTC provided an opportunity for such a demonstration. From the outset the process was explicitly framed as a necessary response to the impacts of global political and economic change on the epidemic of tobacco consumption. Brundtland’s rationale for the convention highlighted
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the extent to which national control measures could be undermined by the global tobacco industry: The actions of individual countries can be ineffective, primarily because of the globalization of trade, marketing, and information. Corporate interests in profits are no longer confined by geography. Moreover, the globalization of the tobacco industry’s marketing strategies have contributed to a breakdown in local and national cultural barriers to tobacco use. Advertising and smuggling do not stop at national borders (Brundtland 2000).
In this context of global change the FCTC was portrayed as ‘a global complement to national actions’, an instrument capable of regulating ‘globalized public health threats, such as tobacco smuggling and cross-border advertising’ (Brundtland 2000). Indeed, the negotiation of the FCTC can be regarded as the paradigmatic example of the WHO’s interest in developing new forms of health governance in response to globalisation ‘as an organizational strategy that promised survival and, indeed, renewal’ (Brown, Cueto, and Fee 2006).1
Negotiating the FCTC While the content of the final text is clearly vitally important to the future prospects of the FCTC, its significance as an innovation in health governance resides primarily in the process of its negotiation. This process has been discussed elsewhere (Collin 2004, 2005; Collin, Lee, and Bissell 2004; Yach et al. 2007; Wilkenfeld 2005). But an understanding of the FCTC in the current context requires illustration of key features such as the role of the World Bank, the contribution of member states, and the terms of civil society participation. The attempts of tobacco companies to undermine the negotiations are then considered in more detail below. The World Bank and the FCTC Establishing a broad-based accommodation with the World Bank was a prerequisite for Brundtland’s reform strategy, reflecting both the dominant status of international finance organisations within the UN system and the World Bank’s de facto displacement of the WHO as the world’s leading international health agency (Brown, Cueto, and Fee 2006; Buse and Walt 2000). The FCTC is doubtless less significant in this context than Brundtland’s adoption of the disability-adjusted life year (DALY) in assessing the cost effectiveness of health interventions, an approach taken from the World Development Report 1993 (Yamey 2002b; see also World Bank 1993); it also also is less significant than the retreat from the Health for All agenda (Thomas and Weber 2004) or the prominence afforded officials from the International Monetary Fund (IMF), the World Trade Organization (WTO), and the World Bank within the Commission on Macroeconomics and Health (Brown, Cueto, and Fee 2006). But the FCTC did provide a valuable context within which to consolidate the WHO’s
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relationship with the World Bank in particular. This was assisted by the fact that World Bank policy on tobacco had long incorporated health concerns, having committed in 1991 to working with countries to reduce tobacco use and refusing to lend for activities supporting tobacco production, processing, or marketing. Additionally, as British American Tobacco ([BAT] 1999) noted, visibly supporting the FCTC advanced the World Bank’s broader strategic interests under its president, James Wolfensohn, having adopted a ‘much broader definition of economic development’ with its leadership being ‘anxious to demonstrate its new-found social conscience’. The increasing engagement of the World Bank played a critical enabling role in the development of the FCTC, and particularly in building support for it among developing countries. A landmark in this regard was the 1999 publication by the World Bank of Curbing the Epidemic: Governments and the Economics of Tobacco Control, which depicted comprehensive tobacco control measures as providing a virtuous circle of enhancing revenue and advancing public health: Policies that reduce the demand for tobacco, such as a decision to increase tobacco taxes, would not cause long-term job losses in the vast majority of countries. Nor would higher tobacco taxes reduce tax revenues; rather, revenues would climb in the medium term. Such policies could, in sum, bring unprecedented health benefits without harming economies (Jha and Chaloupka 1999).
The report made an important formal contribution to the process, being cited by the FCTC working groups as providing empirical evidence to support the demand reduction strategies included in the proposed draft that was adopted as the base text from which the INB initiated negotiations (Yach et al. 2007). The report’s extensive dissemination has been critical in undermining the widespread belief in the existence of net economic benefits from tobacco production and consumption, the pervasiveness of which has historically constituted the single greatest political obstacle to the progress of effective regulation. Its impact was consolidated by subsequent more detailed exploration of economic issues relating to tobacco use in developing countries (Jha and Chaloupka 2000). It is also worth noting the tobacco industry’s internal recognition of the significance of Brundtland’s ability to attract active support from the World Bank to the FCTC’s prospects of success (BAT 1999). Extensive Participation by WHO Member States Given the WHO’s structure as an international organisation, its success in pursuing the convention inevitably relied on the extent to which it could engage the active support and participation of its member states. The level of involvement was generally impressive throughout the protracted process, although inevitably characterised by inequalities across national delegations in terms of their scale and breadth of expertise. Resolution 52.18 was unanimously adopted by the WHA in 1999, with a record 50 states taking to the floor to commit political and economic support (WHO
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1999a). Following two preparatory working groups, the first INB in October 2000 was attended by 148 countries, while the final round of negotiations in February 2003 involved delegations from 171 countries. The demands of attendance and participation have required expanded multi-sectoral collaboration on tobacco issues at national level. For example, formal and informal committees have been established and regular interministerial consultations have been held, often for the first time, in countries as diverse as Zimbabwe, China, Brazil, Thailand, and the United States (Wipfli et al. 2001; Woelk, Mtisi, and Vaughan 2000). The leadership exercised by developing countries in pressing for a strong FCTC rapidly emerged as a distinguishing and perhaps surprising feature of the FCTC negotiations and a key factor in the comparative strength of the eventual text (Hammond and Assunta 2003). Such leadership reflects decisions made both to shape the policy agenda and to manage the demands of participating in protracted Geneva negotiations. Delegates from the WHO’s African region were the first to participate as a regional bloc, and possible divisions between tobacco producing and non-producing countries were avoided by the development of common positions prior to each INB. Such positions heightened the impact of African countries on the negotiations (Bates 2001) and the practice was subsequently adopted by other regions, thus enabling the development of cross-regional alliances such as that between the African and southeast Asian regions. A small number of high-income countries were broadly protective of the interests of transnational tobacco companies, advocating a minimalist FCTC restricted to aspirations and avoiding obligations. This group included Japan and Germany, with the U.S. emerging as their most prominent proponent, particularly following the election of George W. Bush. Democrat representative Henry Waxman highlighted the administration’s efforts to undermine FCTC negotiations via documents indicating that, following a meeting with representatives of Philip Morris, U.S. negotiators pursued ten of eleven requested deletions from proposed text (Waxman 2002). Prior to the final round of negotiations, a leaked memo from the U.S. embassy in Riyadh urged Saudi Arabian assistance in backing U.S. efforts to manage the debate over the relationship between trade and health, encouraging the attendance of delegates from economic ministries to ensure that the perspective of the health department was not unchallenged (Waxman, Durbin, and Doggett 2003). The FCTC and Civil Society The FCTC process included efforts to increase civil society participation within an essentially state-centric policy process, efforts that were necessarily partial and a consistent source of tension among national delegations. The WHO generally allows comparatively circumscribed participation in its proceedings to nongovernmental organisations (NGOs) that have entered into ‘official relations’ with it, a status achieved through a multi-year process by international health-related NGOs. This status allows such organisations to observe proceedings and to make an expository statement at the chair’s invitation, usually confined to a short period at the end of
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a session. The terms of civil society participation remained contested throughout the negotiation process, although there were attempts to ease these restrictions. Following an open consultation held by Canada and Thailand, member states approved recommendations to accelerate the accreditation process and to grant access to open working groups to NGOs in official relations. In October 2000, the WHO held its first public hearings, enabling participation to stakeholders and civil society groups across the tobacco industry and allied groups as well as public health organisations. These clearly provided a limited form of participation, and were perhaps primarily a sop to tobacco interests bemoaning their exclusion. But the hearings did allow some 144 organisations to provide oral testimony, while 500 written submissions were received. The involvement of civil society organisations in the FCTC process was greatly enhanced by the formation and development of the Framework Convention Alliance (FCA). At the initial working groups, civil society participation was largely confined to NGOs from high-income countries and international health-based NGOs. The FCA increased communication among civil society organisations already engaged, and systematically reached out to support new and small organisations, particularly in developing countries. By February 2003 the FCA had established itself as a significant coalition of more than 180 NGOs from more than 70 countries, and had established itself as an important lobbying alliance. Coordinated via the FCA, NGOs in official relations were able to exploit their limited access to fulfil significant lobbying, educational, and monitoring roles. The expertise accumulated within the FCA became a key resource, particularly in a progressive alliance with the African and southeast Asian regions. Additionally, a few prominent advocates were occasionally included within the official delegations of member states (Collin, Lee, and Bissell 2004). Civil society’s contribution to the final negotiations was, however, significantly hampered by increasing unease among member states opposed to a powerful text. The designation of most negotiating sessions of the final INB as informal provided a simple mechanism for the exclusion of NGO participants—a reduction of access and transparency insisted upon by the U.S. and China delegations (Wilkenfeld 2005).
Transnational Tobacco Companies and the FCTC Corporate documents disclosed following litigation in the U.S. provide a unique resource for analysing the role of corporations in international health governance, enabling research of direct policy relevance in the context of FCTC implementation. Preliminary analysis of available documents suggests that the responses of tobacco companies to regulation do not display the uniformity that has traditionally been presumed by health researchers. While a basic antagonism to stringent regulation can certainly be identified and cooperation in many areas confidently predicted, the strategic responses to emergent regulation adopted by tobacco companies diverge significantly according to their respective market status.
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Documents from BAT, Philip Morris International, and Japan Tobacco/R.J. Reynolds unsurprisingly indicate substantial areas of agreement and cooperation in seeking to counter the development of the WHO’s FCTC initiative. An initial meeting between senior executives from the three companies in Geneva in 1999 indicated ‘universal agreement as to the areas in which the companies thought they could or should work together’ (Broughton et al. 1999). Such areas included greater collaboration on youth smoking prevention initiatives, while ‘Independent Voluntary Regulation was clearly seen as an objective by all companies and all wanted to proceed urgently to explore/devise this’. Voluntary regulation was to be projected as an alternative to the more stringent trajectory of the FCTC negotiations, with BAT emphasising that it was ‘critical to have [an] alternative to [the] WHO proposal for consideration’ by governments well in advance of the WHA, while Philip Morris advised that such an initiative should not be presented ‘as [a] response to [the] WHO, but as [a] “New Millennium” for tobacco’. Such cooperation focussed on the development of a global marketing code of conduct and reached fruition in the launch of International Tobacco Products Marketing Standards in September 2001, albeit more modest than that originally envisaged. As the FCTC negotiations progressed, however, it rapidly became clear that such areas of common interest coexisted with substantial divergence in strategy and orientation toward the prospective treaty. BAT was at the forefront of industry hostility to the WHO’s approach, as might be predicted given that its comparative commercial strengths lie in developing countries where accelerated regulation would be expected to have the greatest impact (Fisher 2001). BAT’s proposed strategy for countering the WHO initiative was predicated on recognition of the FCTC as ‘an unprecedented challenge to the tobacco industry’s freedom to continue doing business’ (BAT 1999). Astutely calculating that the political commitment invested in the process suggested that the achievement of a convention was inevitable, BAT sought to moderate its likely scope and impact by adopting a ‘two tier approach: lobbying and reputation management’. BAT’s early lobbying programme aimed at ‘maximising opposition to the TFI [Tobacco Free Initiative] proposals by mobilising the support of key allies at a global, regional and local level’, and claimed ‘some success at a government level’ in securing the agreement of Brazil, China, Germany, Argentina, and Zimbabwe ‘to make submissions to the drafting process’. In January 2000, a memo describing BAT’s objectives in countering the FCTC process within Europe were to ensure ‘the convention [would] be broadly based and [would] not in itself contain concrete measures’, to restrict the negotiation mandate of the European Union, and to ‘gain time’ (Bielefeldt 2000). A subsequent presentation describing key ‘wins’ in the region during 2000 claimed substantial returns on its lobbying efforts: • Key European markets (Russia, Germany) influenced deliberations for broader, less prescriptive convention • Critical ministries (Finance, Tax, Agriculture, Trade) involved
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• Submissions for WHO public hearings (NMAs [national manufacturers associations], trade, advertising industry) secured in Russia, Germany, Hungary, Ukraine, France, Poland … • INB: Constructive input from Russia, Uzbekistan, Belarus, Moldova, Baltics (Lioutyi 2000).
BAT’s public statements regarding the FCTC were notable for the comparative vehemence of their denunciations. Prominence was repeatedly given to claims that the proposed convention constituted an attack on the sovereignty of member states, with the WHO depicted as foisting a first world agenda on developing countries and neglecting its traditional mission in combating communicable disease. Martin Broughton (2000), chair of BAT, depicted the FCTC as embodying a ‘New Colonialism’ that sought to ‘impose the values of the developed world on the developing countries … hindering the socio-economic advancement of the developing world by seeking to undermine their comparative advantage’. Although such criticisms were echoed, less stridently, by Japan Tobacco (Assunta and Chapman 2006), Philip Morris distanced itself from this antagonistic approach and adopted a conciliatory stance. A strategic review in 1999 concluded that ‘WHO benefits from “an uncompromising, ruthless, reasonable and predatory” industry’ and warned that any opposition to the FCTC ‘is likely to be depicted as opposition to the least controversial elements’ (Philip Morris 1999). The process ‘could provide PM [Philip Morris] with an opportunity to constructively engage in a worldwide effort to curb underage use of tobacco products’, rather than view the FCTC only as a threat. The public pursuit of constructive engagement subsequently became the leitmotif in Philip Morris publications. In turn, BAT came to view Philip Morris’s conciliatory stance on regulation as exacerbating the threat to its global interests. As outlined in a summary of the status of BAT’s WHO campaign in 2000: We [BAT] affirmed that the seriousness of regulatory threats against BAT are increasing on the back of the FCTC process and besides the WHO itself … PMI [Philip Morris] presents the other main challenge to our local interests. Essentially, while the FCTC was driving a multilateral regulatory model, its work was fuelling a rise in local regulation, on the back of which we fully expect PMI to exploit the situation and to promote its own competitive advantage. This presents BAT with a dual challenge which we need to meet rapidly … We agreed that given BAT’s heritage, global business structure and objectives, it would be difficult for the group to come up with a standard agreed regulatory formula, or ‘one-size-fits-all’ approach, which PMI would more likely try to propagate—consistent with its public statement of strong support for the FCTC (Vecchiet 2000).
Corporate Social Responsibility and the Avoidance of Regulation While all leading tobacco companies have adopted the language of responsible conduct within a controversial industry, the most enthusiastic advocates have been
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Philip Morris and BAT. These companies have, however, pursued their commitments to corporate social responsibility (CSR) in very different ways, and internal documents suggest that they have done so for different reasons. A published analysis of documents describing the development of CSR within Philip Morris highlights, inter alia, the desire to extricate its corporate image from its close association with litigation, to combat the scale of attacks to which global businesses were increasingly subject, and to engage its employees more effectively (Hirschhorn 2004). In the case of BAT it is impossible to separate the launch of its ambitious CSR initiative, variously referred to as social reporting or social accountability, from the company’s perception of the wide-ranging threat to its global operations posed by increased regulation in general and the FCTC in particular. As outlined by BAT’s corporate social accountability manager Shabanji Opukah (1999), in order to relate the project on the TFI threat, I would analogise as follows—If Brent Spar and the Nigerian Ogoni issues were the major spark that pushed Shell to where they are today with social accountability, then the WHO TFI threat is our spark. If the Colombian environmental and security mess was the one that drove BP Amoco to committing to the social accountability agenda, then the WHO TFI threat is our Colombia. If the community riots and challenges that Rio Tinto faced in Australia were the ones that led to the company’s review of its social responsibility and public commitment to doing something about it then the WHO TFI is our Australian challenge … Time comes when organisations have to be shocked out of their comfort zones and shells and some of this unfortunately may come from externally driven rather than internally inspired and value driven sources. Then for us WHO TFI presents the best opportunity to take forward the big agenda on CORPORATE REPUTATION Management.
Rather than simply providing an external impetus to adopt CSR, documents indicate that BAT’s heightened concern with reputation management and initiation of social reporting was targeted toward undermining the development of the FCTC. A strategy document emphasised the significance of such initiatives, operating in conjunction with the extensive programme of lobbying outlined above: The most elusive part of the campaign—reputation management will require some searching discussion, solid research and hard business decisions. The question we need to ask is: Can the tobacco industry move itself ahead—fast enough and far enough—of the WHO agenda to negate the need for the convention and enhance its reputation in the process (BAT 1999)?
BAT’s foray into CSR recognised the importance of external monitoring if the exercise was to have any credibility. A social reporting process devised by the Institute of Social and Ethical Accountability was selected as a ‘universally accepted standard’, enabling an ‘independently verified account of company performance’ (Prideaux 2000). Crucially, however, the greater transparency entailed by this process did not threaten embarrassment since the company would retain control of its content
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and scope, with indicators being self-determined. The exercise was described as ‘more about “a philosophy and a process” than the “passing or failing of a test”’. Hence on an issue such as youth smoking prevention, it would be the initiative that was assessed rather than any success in reducing the numbers of youths smoking: The company could lead the way by putting into place youth smoking prevention measures to ensure that minors are better educated and less able to buy cigarettes. In this way, early progress would be measured via end-market activities and campaigns rather than by any reduction in underage smoking. In other words, performance would initially be judged on ‘output’ rather than ‘impact’ (Prideaux 2000).
This statement of priorities clearly contradicts those that would be required if a meaningful impact on public health was to be obtained, highlighting the inadequacy of reliance on voluntary regulation to realise such objectives. As envisaged in the summary recommendation that BAT should proceed with a social reporting process on the grounds that it would improve the company’s credibility and provide substantial protection from critics: Overall, it will provide a structured, comprehensive and highly credible framework for dealing with contentious issues and addressing them in a beneficial and sustainable way, supported by pressure groups, academics and governments. In this way, the process will not only help British American Tobacco achieve a position of recognised responsibility but also provides ‘air cover’ from criticism while improvements are being made. Essentially, it provides a degree of publicly-endorsed amnesty (Prideaux 2000).
Both in terms of explaining its genesis and the presumption of voluntarism it incorporates, the adoption of social responsibility initiatives poses a potentially significant challenge to health governance. This is starkly evident with reference to tobacco, where CSR holds the promise of rehabilitating a pariah industry (Collin and Gilmore 2002), and high-profile initiatives such as the International Tobacco Products Marketing Standards could undermine commitments to effective health legislation. More broadly, given increasing interest in viewing not just particular diseasepromoting businesses but also the corporate entity as a social structural determinant of health (Wiist 2006), such voluntary initiatives by the commercial sector could be seen as impeding the development of more interventionist approaches. In this context the FCTC can be seen as an alternative model by which the global conduct of multinational corporations may be regulated (Christian Aid 2004).
The FCTC, Health, and Foreign Policy The scale of inter-sectoral collaboration involved, the breadth of economic and social interests affected, and the significance of the WHO’s first negotiation of an
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international public health treaty mark the FCTC as an appropriate context within which to examine contemporary relationships between policy communities. One conceptual framework within which to examine how public health concerns interact with foreign, development, and trade policy agendas identifies four basic models of supplicant, Trojan horse, partnership, and independent actor (Lee and McInnes 2004). Each of the models can be regarded as plausibly depicting some aspect of the FCTC process, albeit from conflicting perspectives. Supplicant The image of public health as supplicant to more powerful and better resourced policy communities describes an attempt to secure funding and support through advocating the benefits of global health for stability and economic growth. Such an image is consistent with a broader critique of the WHO strategy under Brundtland as embodying a largely uncritical adoption of neo-liberal economic orthodoxy (Thomas and Weber 2004). The Commission on Macroeconomics and Health, for example, was explicitly predicated on making an economic case for promoting global health, downgrading any emphasis on health as a fundamental human right (Waitzkin 2003; Banarji 2002). While such a strategy may be entirely understandable from a realpolitik perspective, the advantages of winning powerful allies may be offset by precluding policies necessary for the achievement of core public health objectives. The FCTC process could be viewed as exhibiting such characteristics given both the WHO’s reliance on the World Bank in demonstrating the economic case for tobacco control and its desire to secure the support of donor countries. Such concerns were voiced during the final negotiations, when the weak provisions on advertising in the proposed text were criticised as inadequate and as subordinating FCTC objectives and the preferences of developing countries to those of a handful of obdurate states such as the U.S., Germany, and Japan (Fleck 2003; Action on Smoking and Health 2003). The constraints imposed by operating within the ideological confines of neoliberalism are most dramatically evident in the clear subordination of the FCTC to trade agreements implicit in the text submitted to the penultimate round of negotiations: Article 2(3) Nothing in this Convention and its related protocols shall be interpreted as implying in any way a change in rights and obligations of a Party under any existing international treaty … Article 4(5) While recognizing that tobacco control and trade measures can be implemented in a mutually supportive manner, Parties agree that tobacco control measures shall be transparent, implemented in accordance with their existing international obligations, and shall not constitute a means of arbitrary or unjustifiable discrimination in international trade (WHO 2002).
It nevertheless failed to include any ‘health over trade’ language despite both the powerful evidence base regarding the impact of trade liberalisation on tobacco
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consumption (Taylor et al. 2000; Chaloupka and Laixuthai 1996) and widespread support among member states. While the vast majority of developing countries and civil society organisations supported the inclusion of language that would protect the FCTC from challenge within the WTO, such a position received no significant support among high-income countries and was never advocated within the TFI. The FCTC text therefore exhibits a striking contrast between the prominence accorded to the health impacts of trade liberalisation and foreign direct investment (FDI) in its justification and the absence of any provisions to address such processes. Trojan Horse In this context a Trojan horse relationship describes public health appealing to traditional foreign policy concerns in order to establish its political salience, from which position a health agenda can then be promoted. While such an interpretation of the FCTC has not been advanced by public health advocates, it is consistent with accounts that question the legitimacy of the convention and of the WHO’s role in its development. Perhaps predictably such arguments have been advanced by tobacco companies (Broughton 2000; Assunta and Chapman 2006) and by related organisations and individuals. The support of the World Bank drew particular antipathy from liberal commentators, with Curbing the Epidemic dismissed as ‘not a decent economic study, but a document for crusaders’ (Tren and High 2000). In a similar vein, the right wing British philosopher Roger Scruton (2001) lengthily attacked what he identified as the WHO’s abandonment of its mandate in favour of ‘proposing a world-wide socialist programme, and using the concept of a human right to imply that there is a moral and political duty to impose it’. The credibility of Scruton’s account was arguably somewhat undermined by the subsequent disclosure that it formed part of a lucrative consultancy for Japan Tobacco (Kmietowicz and Ferriman 2002). A more significant critique is provided by Gregory F. Jacob (2004), an expert in constitutional law in the U.S. Department of Justice Office of Legal Counsel, in the most severe analysis of the FCTC process delivered by a key participant in the negotiations. His role in the U.S. delegation was to ensure that the treaty that emerged should be consistent with constitutional requirements. Although professing sympathy with FCTC objectives, Jacob was vehement in his criticism of the negotiation process, aspects of the final treaty, and the conduct some participants (notably civil society organisations). He summarised his position by saying that ‘the FCTC is an imperfect document produced by a deeply flawed process’, a process he regarded as ‘broken, inefficient, and generally inimical to United States interests’. The U.S. approach to the negotiations was presented as a reflection of the greater weight it accords to obligations in international law, in contrast with an alleged indifference among other delegations to implications for implementation. Jacob was critical of the WHO’s management of the negotiations, identified its regional structure as encouraging a split between developed and developing countries, and regarded the language dealing with advertising and sponsorship as so broad as to
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be meaningless. The treaty that emerged was seen as having ‘remarkably little to do with international relations’, with the intended framework convention approach being jettisoned in response to pressure from advocacy groups: A framework convention is supposed to broadly state general governing principles on which all countries can agree and then spin off related optional protocols that contain more specific substantive obligations … the framework model did not serve the needs of the NGOs, the health ministers who were looking to force the hands of their own governments, or the trade lawyers who were looking for a little extra help in the trade courts. Figuring that international political pressure would push countries into signing the main Convention but would not extend far enough to push them into optional protocols, the groups in question undertook to pack the Convention full of all the substantive provisions that were on their wish lists (Jacob 2004, 299).
This account arguably reflects a somewhat jaundiced view of the dynamics of the FCTC, ignoring the extent to which the strategies of many participants were shaped by a perceived need to prevent the comparatively isolated U.S. position from determining the contents of a treaty it was extremely unlikely to ratify. But Jacob does highlight significant problems with the process and content of the FCTC, and can be more broadly viewed to be illustrating tensions inherent in pursuing public health objectives using an instrument of international relations. Partnership By contrast, an interpretation of the FCTC as a partnership between health and other policy communities offers the most highly idealised interpretation of its development. This pattern describes a relationship in which the skills and interests of several communities are brought together to mutual benefit, but without any one policy community being dominant or privileged. This depiction accords strongly with how the WHO has sought to present the process of FCTC negotiation, providing what could be termed its hagiography. The FCTC has been presented by Jennifer Prah Ruger (2004; 2005) as emblematic of a powerful new approach within development policy, demonstrating how health agencies can work with other institutions and actors to promote global health goals: Through the FCTC, ministries of health and health-related associations, such as physicians groups, are united with ministries of finance, economic planning, taxation, labour, industry, and education as well as with citizen groups and the private sector, to create a multisectoral national and international tobacco-control effort. The FCTC represents a growing trend in development policy toward an alternative paradigm that is broad, integrated, and multifaceted (Ruger 2004, 1080).
In combination with the unparalleled cooperation across diverse government ministries, the collaboration between the World Bank and the WHO that characterised
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the FCTC process is here viewed as indicating a paradigmatic shift in tobacco control but which has broader roots and relevance (Ruger 2005). Indeed, the FCTC is described as ‘representing a shift in global health policy that recognizes the importance of addressing health needs on multiple fronts and integrating public policies into a comprehensive set of health improvement strategies’ (Ruger 2005, 65–66). In this vein Ruger depicts the FCTC as consistent with Amartya Sen’s (1999) capability approach in which development is seen as the expansion of individual freedom. Public Health as an Independent Actor While each of the above models of the relationship between public health and foreign policy communities captures significant features of the FCTC, none is entirely convincing as an account of the process. The image of public health as supplicant implies a degree of subordination to other agendas, which, although it may be reasonably applied to Brundtland’s leadership project for WHO reform by defenders of the 1978 Alma Ata agenda (the first international declaration to underline the importance of primary health care), does not fit well with the particular experience of tobacco policy. Brundtland was remarkably successful in establishing WHO leadership throughout international organisations on tobacco issues, and the comparative strength of the eventual text bears testimony to the primacy of a health agenda within the FCTC process. The credibility of the Trojan horse interpretation is, at least from a public health standpoint, undermined through its advocacy by tobacco companies, their apologists, and hired hands. Many veterans of the negotiations would doubtless be happy to include the U.S. delegation among these dubious ranks, but Jacob’s status as a key participant lends his critique greater significance. His account, however, offers a caricature of the negotiation process that greatly exaggerates the impact of civil society organisations, gives an inadequate (and often patronising) account of the role of developing countries, and is silent on the controversies surrounding the U.S. contribution to negotiations. The impact of his scathing account is also somewhat diluted by the endorsement that he ultimately lends the prospect of U.S. ratification of the FCTC and his approval of the broader impacts of the process. By contrast, the partnership model accurately portrays important drivers of the process, particularly regarding relations between UN agencies. But this interpretation of the relationship between policy communities leaves important questions unasked regarding the terms on which such communities are brought together, the power dynamics between them, and the basis on which disputes are resolved (Lee and McInnes 2004). The image of public health as an independent actor ultimately appears to offer the most convincing depiction of the FCTC, since it most clearly recognises the leadership role of the WHO and the primacy of public health in agenda setting and policy formulation. At the global level, the WHO actively sought the support of other UN agencies and particularly the World Bank for an innovative health policy agenda. Brundtland’s global tobacco control initiative appealed to the foreign
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policy community as clear and goal oriented and as allowing for negotiation. Accommodations were clearly sought with the concerns of other actors, but while social and economic aspects of tobacco production and consumption were clearly significant, it is clear that the primary driver of the process was the global health impacts of tobacco use. Similarly, at the level of member states, the breadth of measures considered during negotiations required substantial interdepartmental collaboration. In both national and global arenas, the FCTC provided encouraging instances of public health being able to attract support from traditional sources of hostility. Nonetheless, the FCTC remained a health initiative, and the engagement of other policy communities was more partial than a partnership model might imply.
Assessing the FCTC Any attempt to offer a definitive assessment of the FCTC is still premature, whether with regard to its prospects for countering the tobacco pandemic or its wider implications for health governance. It entered into force in February 2005 following its 40th ratification, and the Conference of the Parties (the convention’s principal organisational form) met for the first time in Geneva in January 2006. Yet it is already clear that in several respects the FCTC can be regarded as having been enormously successful. The very fact that the WHO succeeded in its first attempt to negotiate an international public health clearly is a marker of the FCTC’s historic significance in health governance and bears testimony to Brundtland’s revitalisation of what had seemed in danger of becoming a moribund organisation. Although the final text is clearly far from flawless, it received enthusiastic support from public health professionals and advocacy groups and is undoubtedly a more impressive document than appeared likely even during the later stages of negotiations. The extensive participation of member states across the two working groups and six INBs has subsequently been mirrored by the remarkably rapid and widespread support for the convention, among the fastest of any UN treaty, reaching 157 ratifications by June 2008 (WHO 2008). The primary value of the FCTC to date, however, resides less in the attributes of the formal text and its ratification than in the more diffuse global impacts of the process in providing an impetus to tobacco control efforts. The negotiations stimulated rapid developments in civil society, for example, with the FCA now resembling an emergent social movement for global tobacco control. The unprecedented scale of multi-sectoral collaboration at national level, increased salience and improved coordination across UN agencies, recognition of the potential contribution of tobacco control to development, and the raised interest of donor agencies all contributed to a profusion of local and national tobacco control initiatives. Such momentum is reflected in the increased pace of policy transfer and ‘leapfrogging’ across regional and global levels. Within the European Union, comprehensive legislation for smokefree public places has been adopted by, among others, Sweden, Spain, Italy, France, Denmark, Romania, the Netherlands, and Ireland, with Scotland inducing a domino
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effect across Wales, Northern Ireland, and England. Canada’s adoption of large graphic health warnings has subsequently been replicated by Thailand, Brazil, the EU, and elsewhere—an issue on which national policy development and FCTC negotiations clearly interacted. Such progress is not formally part of the FCTC, but is impossible to understand in isolation from it. As Philip Morris senior vice-president David Davies (2003) recognised in a speech to a tobacco industry conference in November 2003: We have lived with regulations and other restrictive policies in this industry for a long time now. A major shift in our environment is of course the adoption of the FCTC. While the convention has been signed by more than seventy countries, it has been ratified by only five. Whether ratified or not, the treaty has had a significant influence on us, simply because it has accelerated the pace of regulation in individual countries.
The significance of such successes notwithstanding, there are inevitably questions about the capacity of the FCTC to fulfil its objectives. While the final text was widely welcomed within the public health community, the enthusiasm of its reception owed much to the despair with which the penultimate draft had been received. The coalition of countries and civil society organisations pressing for a strong FCTC did not entirely prevail over those states advocating a minimalist convention. The defining dispute of the negotiations was regarding the tensions between tobacco control and trade liberalisation, and the clear majority of countries pressing for a privileged position for health measures was not reflected in the final text. While from a public health perspective this still constitutes a clear advance on the stark subordination of the FCTC to trade agreements of prior texts, the convention’s silence on such issues can be seen as representing a triumph of U.S. diplomacy and as exposing the extent to which the FCTC has been circumscribed by liberal economic orthodoxy. An optimistic assessment of the relationship between the FCTC and trade agreements highlights the language of the FCTC’s preamble, in which the parties are described as ‘determined to give priority to their right to protect public health’ (WHO 2003). In the case of future disputes, it has been argued, this could be construed as indicating an intent to allow non-discriminatory tobacco control measures even where trade is adversely affected (Yach et al. 2007). This appears a rather thin reed on which to build such hopes, but a more definitive verdict must await the arbitration of future challenges, with the FCTC’s requirements on large health warnings and bans on misleading descriptors seeming likely targets for challenge. The achievement of a convention can itself be seen as posing challenges for tobacco control, most notably with regard to ensuring effective implementation of its provisions. The prospect of perverse impacts cannot be disregarded, since the very impact of the FCTC in accelerating national legislation could also be viewed as creating new opportunities for tobacco companies to shape public policy. In 2004, just days after Mexico’s ratification of the FCTC, the government announced an agreement with three tobacco companies that clearly contradicted FCTC obligations on health warnings, ingredients disclosure, and sponsorship (Samet et al. 2006). In
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Malaysia, a half-day consultation exercise by the ministry of health to bring product regulations in line with FCTC obligations provided extensive representation to tobacco industry personnel (Simpson 2006). In Argentina, following the drafting of bills designed to ratify the FCTC by legislators and the executive, pro-tobacco senators introduced a competing bill ‘to create a commission to follow and control the implementation of the FCTC’ (quoted in Sebrié et al. 2005). Such examples indicate that while the inability of many governments to overcome industry resistance to tobacco control was a key driver of the FCTC process, it is by no means clear that the convention provides a sufficient resource to enable countries to withstand such opposition. A further potential problem arising from the realisation of the FCTC is a decline in political commitment and resources devoted to tobacco control. Brundtland’s departure as director general in 2003 inevitably raised concerns about reduced political capital within the WHO, given the degree of her personal association with the FCTC. Despite the apparent enthusiasm among member states suggested by rapid ratification, in a survey for the first Conference of the Parties one quarter of high-income countries reported no current or future support of tobacco control initiatives (WHO 2006b). Several donors, including the World Bank, have reduced their commitment (Yach 2005), reinforcing a sense that tobacco may have had its day in the sun. Such caveats and concerns notwithstanding, however, the FCTC already appears a remarkable achievement by any reasonable criterion. It stands alongside the Codex Alimentarius Commission for food standards and the revised International Health Regulations as established international health norms (Yach et al. 2007). An indication of its wider significance as a development within health governance is provided by the increased interest of advocates for other health issues, notably the obesity epidemic, in developing equivalent international instruments (Chopra and Darnton-Hill 2004). While it remains to be seen whether the FCTC process can sustain the momentum necessary to ensure its transformation from an international health treaty to a global movement for public health, there have been promising recent developments. The announcement in 2006 of Michael Bloomberg’s US$125 million, two-year initiative transformed the financial context of global tobacco control, more than doubling the total of private and public donor resources in developing countries and with the WHO as a key partner (WHO 2006a). Equally significantly, the first Conference of the Parties in February 2006 undertook to begin the development of two protocols covering cross-border advertising and illicit trade. It is through such negotiations that more detailed, binding commitments to advancing tobacco control can be advanced and the potential of the FCTC be best realised.
Note 1 Theodore Brown, Marcos Cueto, and Elizabeth Fee (2006) analyse the WHO’s increasing emphasis on global rather than international public health, based on an account of the
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‘new global health’ published by WHO officials Derek Yach and Douglas Bettcher in 1998; yet they fail to consider the roles of Yach and Bettcher as key architects of the FCTC in their analysis.
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Part VI Defining Future Directions in Global Health Governance
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Chapter 13
Forging the Trade Link in Global Health Governance Benedikte Dal, Laura Sunderland, and Nick Drager
Health is increasingly central to foreign policy. Indeed, health is being explicitly incorporated into trade agreements, so that practitioners of global health diplomacy must be innovative in resolving the growing tensions between trade and health. This chapter begins by exploring public health in today’s globalised world. It then examines the concept of global health diplomacy and its ever more important role in the relationship between health and trade. It discusses the role of the Intergovernmental Working Group on Public Health, Innovation, and Intellectual Property (IGWG) of the World Health Organization (WHO) and the WHO’s efforts to achieve policy coherence at the national and international levels.
Public Health in a Globalising World Because health is now central to the global policy agenda, there is a new context for public health. The interdependence produced by globalisation has broken down traditional ways of conceptualising and organising the medical, economic, political, and technological means to improve health. Nowhere is this transformation more apparent than in the rise of health as a foreign policy and trade concern. This relationship between health, foreign policy, and trade is vital, complex, and frequently debated. To craft health policy today, governments, international institutions, and nongovernmental organisations (NGOs) must find mechanisms to manage health risks that spill into and out of every country (Drager and Fidler 2007). Improving health outcomes is critical to achieving the benchmarks of success that the international community has set for itself, such as the Millennium Development Goals (MDGs). Countries now must take into account cross-border spill-ins and spillovers when crafting health policy. Yet there is still a tendency to look inward, in the country and in the sector, when national health plans are made. The WHO, which under its constitution works with its member states toward the attainment of the highest possible level of health for all people, is trying to get actors in domestic health planning to look outward—into threats that spill into and out of the country. Countries remain core actors in terms of defining health policy. They therefore must be encouraged to
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‘reorient their health and foreign policies in ways that align their national interests with the diplomatic, epidemiological and ethical realities of a globalized world’ (Drager and Fidler 2007). Domestic health planners must increasingly work with their ministries of foreign affairs and trade and think more broadly outside their mandate in order to resolve pressing health issues in a globalised world. Health ministries must work to identify ‘how they can best inform pre-negotiation trade positions, provide input during negotiations, analyze the health costs and benefits of proposed compromises and monitor the health impacts of trade agreements’ (Drager and Fidler 2007). Domestic action alone is no longer sufficient to protect and assure population health. Collective action in essential, as is coordination of international policies. The new global health context of new rules, actors, markets, and tools accordingly requires new, innovative responses. Global governance needs rethinking in terms of global health issues. The relationship between globalisation and global health is increasingly complex, because of the growing integration of economies and societies world-wide, across a wide range of spheres. Globalisation is a circular interaction among three elements: cross-border flows of people, goods, services, money, and ideas; the opening of economies; and the development of international rules and institutions (see Drager and Sunderland 2007, 68–69). Those rules and institutions dealing with trade and health directly affect national economies and health-related sectors and, ultimately, affect population health. This globalised reality of health has created the phenomenon of global health diplomacy.
Global Health Diplomacy Global health diplomacy reflects the reality that international diplomacy now encompasses many traditionally so-called soft issues, such as health, that increasingly have hard implications for national economies (Kickbusch, Silberschmidt, and Buss 2007). It brings together the disciplines of public health, international affairs, management, law, and economics to focus on negotiations that shape, manage, and influence the global policy environment for health. Global health diplomacy includes negotiating for health across boundaries, influencing the global health architecture and governance structures, ensuring access to global public goods for health, and managing the relationship between foreign policy, trade, and health. According to Ilona Kickbusch, Gaudenz Silberschmidt, and Paolo Buss (2007, 230), the world of global health diplomacy is one in which ‘the art of diplomacy juggles with the science of public health and concrete national interest balances with the abstract collective concern of the larger international community in the face of intensive lobbying and advocacy’. Both the WHO’s Framework Convention on Tobacco Control (FCTC) and revised International Health Regulations ([IHR] 2005) are outcome of long negotiating processes that involved multiple actors. The FCTC, the first international public health treaty, reaffirms the right of all people to the highest standard of health and was
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developed in response to the globalisation of the tobacco epidemic (WHO 2003a; see also Chapter 13). It was widely recognised that public health should override other interests. The IHR(2005) set forth an integrated framework in which public health objectives are interconnected with international norms and agreements on trade, human rights, environmental protection, and security, with a view to achieving global health security (WHO 2005). A key component of revision process was the balance between the maximum protection of health and minimum interference in world trade. More global health issues are emerging, such as climate change, the migration of health professionals, innovation, intellectual property, trade and food security, and trade in health services; these issues are complex and difficult to resolve. They require innovative strategies and alliances to reach consensus on possible solutions that link domestic and foreign policy, health, and trade. In terms of the WHO, global health diplomacy is a way of managing external policy for global health. Historically, the organisation brings together actors from diverse sectors to promote health. It has been doing this since it was created in 1948, successfully eradicating smallpox, establishing the recent international health rules on tobacco, and revising the IHR. In this past, however, this form of active international cooperation on health-related goals was not framed as global health diplomacy. But as the issues have become increasingly complex and require international regulations, the notion of global health diplomacy has become central to negotiations between conflicting interests and actors.
The Intergovernmental Working Group on Public Health, Innovation, and Intellectual Property In May 2003, the 56th World Health Assembly (WHA) adopted resolution WHA56.27, which created the Commission on Intellectual Property Rights, Innovation, and Public Health (CIPIH) to develop the concept and practice of global health diplomacy (WHO 2003b). The CIPIH’s mission was to review the linkages between intellectual property rights, innovation, and public health in light of current evidence and to examine in depth how to stimulate the creation of new medicines and other products for diseases that mainly affect developing countries. In May 2006, member states asked the WHO to establish the IGWG, with the mandate to prepare a global strategy and plan of action on essential health research (WHO 2006). The goal is to secure an enhanced and sustainable basis for needsdriven, essential health research and development (R&D) relevant to diseases that disproportionately affect developing countries by proposing clear objectives and priorities and estimating funding needs in this area. The Secretariat for Public Health, Innovation, and Intellectual Property was established in September 2006 to facilitate the IGWG’s work. The working group, composed of WHO member states, held its first session on 4–8 December 2006 in Geneva. It met again on 5–10 November 2007 and 28 April–3 May 2008.
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A strength of the IGWG is that it is an intergovernmental process, shaped by the more than 100 participating countries (along with experts from civil society and academia), rather than by the WHO secretariat. As a result, there has been significant government involvement from the beginning. Some may argue that the diversity of state interests in such processes lowers the bar and progress is rarely made. However, because of the inclusive negotiating process, there is rigid adherence to the text of the report that the working group agreed upon. The negotiating dynamic that has developed is positive, with all parties involved and making submissions. The WHO also held two web-based public hearings—1 to 15 November 2006 and 15 August to 30 September 2007—to provide an opportunity to everyone, including the general public, to become involved. Such an intergovernmental process is the basis of global health diplomacy—strong countries from all parts of the world move in a common direction on an issue, and others eventually are persuaded to follow. The 2006 CIPIH report made 60 recommendations on intellectual property and global health in several areas, including discovery, development, delivery, the encouragement of innovation in developing countries, and the way forward. The draft global strategy and plan of action on public health, innovation, and intellectual property focussed on eight principle topics: prioritising R&D needs, promoting R&D, building and improving innovative capacity, transferring technology, managing intellectual property, improving delivery and access, ensuring sustainable financing mechanisms, and establishing monitoring and reporting systems (IGWG 2007). Because a large part of the negotiations include pushing R&D funds toward diseases of the poor and exploring the dynamics of those markets, many countries appoint intellectual property experts to their delegations to deal with this sensitive and divisive issue. The global action plan developed by the IGWG is a non-binding global strategy, and was presented to the WHA in May 2008. Once WHO regulations and framework conventions are ratified, states will be required to opt out rather than opt in, resulting in a significant amount of peer pressure for states to remain within the system. The major global health and trade issues include: • avian influenza and pandemics, and the IHR; • follow up to the CIPIH report; • the implementation of paragraph 6 of the delcaration on Trade-Related Intellectual Property Rights (TRIPS) and public health (World Trade Organization [WTO] 2003), which calls for flexibility so countries that cannot produce pharmaceuticals can import patented drugs made under compulsory licensing; • requests and offers made under the General Agreement on Trade in Services (GATS) as well as domestic regulation disciplines; and • the implementation of WHA trade and health resolutions (see Appendix 13‑1). There has been a shift in the delegations from member states attending global health negotiations, and this has been apparent at the IGWG negotiations. The participants no longer represent only ministries of health, but also ministries involved in foreign
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affairs, trade, intellectual property, justice, and regulatory drug authorities, as well as national trade negotiators from the Geneva-based World Trade Organization (WTO) and other intergovernmental organisations (IGWG 2008). In addition, as trade is dealt with by the European Commission, the European Union intervened on behalf of its members as well as countries acceding to the EU. This expansion of actors, coupled with the continuing strong negotiating position of developing countries, reflects the continuing paradigm shift of global health diplomacy in the governance of the WHO. Civil society has played an important role in participating in, reporting on, and disseminating the proceedings.
Health and Trade: Forging the Link Examining the relationship between trade and health reveals both conflict and ambitious efforts to increase policy coherence. Historically, countries focussed on ensuring that international trade was not restricted or impeded by health concerns. Today, the ‘WHO’s work on trade and health policy coherence reveals increasing country-level commitment to, and sophistication about, strategies to promote trade and protect health in ways that are politically feasible, economically attractive, epidemiologically informed and ethically sound’ (Drager and Fidler 2007). Four of the multilateral trade agreements of WTO that may affect public health are particularly important to the WHO’s work: the GATS, the Agreement on the Application of Sanitary and Phytosanitary Measures (SPS Agreement), the Agreement on Technical Barriers to Trade (TBT Agreement), and the TRIPS Agreement. There is a clear linkage between trade and health in terms of patent law and food safety regulations (see Drager and Sunderland 2007, 76). Conversely, there are health rules that affect trade, such as the IHR. Although the revisions to the IHRwere negotiated at the WHO, it was important to include the WTO in order to ensure that both organisations were on board with the outcomes. To maintain a good working relationship and close cooperation, the WHO and WTO continue to carry out joint missions, training sessions, and senior-level meetings. Trade in health services is another major issue for domestic concern, second only to the issues of TRIPS and accession to the WTO. Trade in health services is a trillion-dollar industry, ruled by the GATS. There are four modes of trade that pose risks to health while simultaneously providing opportunities to improve health: cross-border supply of services, consumption abroad, commercial presence, and presence of persons (see Drager and Sunderland 2007, 75). Each mode also competes for prominence within the larger domestic economy. A case to consider is e-health, where one benefit is the ability of consumers to stay in the country to seek treatment via electronic communication; but consumers may also go abroad to seek treatment, and there is significant migration of health professionals. Mode 4 of the GATS includes the globalisation of health services, which will happen more as patients look for the least expensive treatment: occasionally it costs less to fly to another country and spend tourism money there than to get treatment at home. The
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WHO is concerned about the effects of this trend on the local population and the impacts of internal brain drain, equity, and price. The basic premise put forward by the WHO is that national stewardship of the health system in the context of the GATS requires an understanding of the current and potential effects of trade in health-related services on a country’s health systems and policy. A country must get its own house in order before inviting in the neighbours. This is also true of the need for developing a strong and sustainable population health policy before integrating one’s country into the WTO (see Appendix 13-2). If a country opens sectors up to trade, proper policies must be in place to protect population health. GATS provide countries with choices and does not force them to make liberalisation commitments that are not in their best interest. If a country is unsure of the effect, it is fully within its rights to decline to make legally binding commitments under GATS. Health policy principles that should guide the liberalisation of health-related services include the involvement of both civil society and private industry to ensure participation of stakeholders toward achieving national goals. Improving access and affordability of health-related services should also be a goal of the liberalisation process. The GATS constitutes a very important trade agreement from the perspective of health. The interface between the agreement and health will be most significantly shaped by the ongoing and subsequent efforts to liberalise trade in services progressively. In light of this reality, countries need to develop informed and sophisticated approaches to managing the GATS process, its results, and future liberalisation efforts.
Working Toward Trade and Health Policy Coherence The WHO works to achieve greater policy coherence between trade and health policy so that international trade and trade rules maximise health benefits and minimise health risks, especially for poor and vulnerable populations. The purpose is to strengthen capacity in ministries of health so they can work effectively with their colleagues in the ministries of trade, commerce, and finance to shape the trade policy environment for health. The objective is to support member states to achieve greater coherence between international trade and health policy, focussing on building the knowledge base and to provide training and country support to strengthen capacity within the WHO and among WHO member states to act on the implications of trade and trade agreements for health. Policy coherence requires a common understanding of the key trade and health policy issues through ongoing dialogue and interaction. It also requires a clear commitment and ministry of health leadership to work toward trade and health policies that mutually support human development objectives. Sustainable institutional mechanisms and the use of innovative instruments and appropriate incentives are necessary to enhance coherence. Early and effective stakeholder involvement builds
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trust among the actors and emphasises the importance of transparency in policy decision-making processes. Actors must get the evidence right, including costing and financing options accurately in proposing alternatives. Progress must be measured, tracked, and evaluated, and the direction of the policy should be altered if necessary. The final important step is that all actors involved in health and trade policy must develop negotiating skills in order to ensure effective and successful cooperation and collaboration. Progress in coordinating trade and health policy is being made. At the country level, countries are increasingly interested in encouraging collaboration between the ministries of health and trade. India has a trade unit in its health ministry that can respond quickly to queries on trade and health. Thailand has developed a coordination mechanism so the ministry of trade systematically passes requests that touch on trade and health to the ministry of health for advice. The trade ministry may not always follow the advice of the ministry of health, but health experts are engaged in the process and give their opinions on matters that affect population health. In terms of global policy coherence and collaboration between the WHO and the WTO, there are high-level policy consultations and governance meetings. The WTO has observer status at WHO governing body meetings and various technical meetings. The WHO has observer status at the WTO’s committees on the SPS and TBT agreements, and ad hoc observer status at its councils for the GATS and the TRIPS Agreement. There is also collaboration between the two organisations on research and analysis, country missions, regional and national meetings, training courses, and informal consultations. Members of the WHO attend WTO ministerial meetings as observers. They sit in on sessions and can speak when asked to comment; they are asked to leave the session during formal negotiations. One challenge with speaking at such a meeting, however, is that diverse and even divergent requests from various groups get bundled together and the negotiations become more challenging.
Diagnostic Tool and Companion Workbook The WHO is collaborating with its members and other international organisations to create a diagnostic tool and companion workbook on trade and health. These are intended to ‘help health and trade ministries more systematically assess trade and health issues, to empower health ministries to give better advice to their trade counterparts and to enhance health policy input into the trade community’s pursuit of integrated frameworks, trade policy reviews and aid initiatives to bolster trade capacities in developing countries’ (see Appendix 13-3) (Drager and Fidler 2007). The diagnostic tool examines five components of the trade and health relationship: macroeconomics, trade, and health; trade in health-related products, including medicines and issues related to intellectual property; trade in products hazardous to health, such as tobacco products; trade in health services—e-commerce, health tourism, foreign direct investment (FDI) in health, cross-border movement of
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health professionals; and trade in foodstuffs. The diagnostic tool and its companion workbook will document best practices, data sources, decision trees, international norms, and standards. It is designed to support the preparation of national papers, which should help governments to assess opportunities and risks associated with international trade rules and greater cross-border flows of goods, services, and capital; adopt strategies to harness benefits and prevent or mitigate negative impacts; facilitate the participation of health authorities in the trade policy-making process; and help health authorities structure their requests for capacity building. During the first phase of development, the countries conceptualised and developed the tool itself. Low- and middle-income countries led the process and the WHO had an advisory group that received the outputs. When complete, the diagnostic tool and its companion will be publicly available, but the country papers produced using the tool will go through processes to make certain confidential information is available only to those who commissioned the analysis. The WHO promotes transparency and stakeholder analysis generally in this area, however, as these issues affect many groups and much can be learned from other countries.
Conclusion Integrating health fully into foreign and trade policies is an essential undertaking in order to achieve the goal of health for all. Policy coherence in the health and trade sectors is thus required. But the reality is that competition among national interests can impede true policy coherence. The WHO and the WTO continue to measure institutional success using very different indicators—population health and trade liberalisation respectively. Finding policy coherence in this situation is challenging but crucial, and requires innovation in global health diplomacy and deep and continued cooperation among ministries of health, trade, and foreign affairs. The WHO is seeking incremental but real progress toward health and trade policy coherence by building trusting, long-term partnerships between it and the WTO that will build momentum toward the ultimate goal of health for all.
References Blouin, Chantal, Nick Drager, and Richard Smith, eds. (2005). International Trade in Health Services and the GATS: Current Issues and Debates. (Washington DC: World Bank and World Health Organization). Commission on Intellectual Property Rights, Innovation, and Public Health (2006). Public Health: Innovation and Intellectual Property Rights. World Health Organization, Geneva. <www.who.int/entity/intellectualproperty/documents/thereport/ENPublicHealthReport. pdf> (September 2008). Drager, Nick and David P. Fidler (2007). ‘Foreign Policy, Trade, and Health: At the Cutting Edge of Global Health Diplomacy.’ Bulletin of the World Health Organization, vol. 85, no. 3, p. 162. <www.who.int/bulletin/volumes/85/3/07-041079.pdf> (September 2008).
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Drager, Nick and Laura Sunderland (2007). ‘Public Health in a Globalising World: The Perspective from the World Health Organization.’ In A.F. Cooper, J.J. Kirton, and T. Schrecker, eds., Governing Global Health: Challenge, Response, Innovation, pp. 67–78 (Aldershot: Ashgate). Intergovernmental Working Group on Public Health, Innovation, and Intellectual Property, (2007). ‘Public Health, Innovation, Essential Health Research, and Intellectual Property Rights: Towards a Global Strategy and Plan of Action.’ 31 July, A/PHI/IGWG/2/2. World Health Organization, Geneva. <www.who.int/gb/phi/pdf/igwg2/PHI_IGWG2_2-en.pdf> (September 2008). Intergovernmental Working Group on Public Health, Innovation, and Intellectual Property, (2008). ‘List of Participants.’ 28 April, A/PHI/IGWG/2/DIV/2 Rev.2. World Health Organization, Geneva. <www.who.int/gb/phi/pdf/igwg2/PHI_IGWG2_DIV2_REV2.pdf> (September 2008). Kickbusch, Ilona, Gaudenz Silberschmidt, and Paulo Buss (2007). ‘Global Health Diplomacy: The Need for New Perspectives, Strategic Approaches, and Skills in Global Health.’ Bulletin of the World Health Organization, vol. 85, no. 3, pp. 230–232. <www.who.int/ bulletin/volumes/85/3/06-039222.pdf> (September 2008). Mattoo, Aaditya, Robert Mitchell Stern, and Gianni Zanini, eds. (2007). A Handbook of International Trade in Services. (Oxford: Oxford University Press). (September 2008). World Health Organization (2003a). The WHO Framework Convention on Tobacco Control. <www.who.int/tobacco/framework/WHO_FCTC_english.pdf> (September 2008). World Health Organization (2003b). ‘Intellectual Property Rights, Innovation, and Public Health.’ 26 May, WHA56.27. <www.who.int/gb/ebwha/pdf_files/WHA56/ea56r27.pdf> (September 2008). World Health Organization (2005). ‘Revision of the International Health Regulations.’ Geneva. <www.who.int/entity/csr/ihr/IHRWHA58_3-en.pdf> (September 2008). World Health Organization (2006). ‘Public Health, Innovation, Essential Health Research, and Intellectual Property Rights: Towards a Global Strategy and Plan of Action.’ 27 May, WHA59.24. <www.who.int/gb/ebwha/pdf_files/WHA59/A59_R24-en.pdf> (September 2008). World Trade Organization (2003). ‘Implementation of Paragraph 6 of the Doha Declaration of the TRIPS Agreement and Public Health.’ Decision of the General Council of 30 August. <www.wto.org/english/tratop_e/trips_e/implem_para6_e.htm> (September 2008).
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Appendix 13-1: Implementing the Resolution on International Trade and Health Resolution WHA59.26 requests the director general and the WHO to: • Provide support to member states to frame coherent policies to address the relationship between trade and health. • Respond to member states’ requests for support of their efforts to build capacity to understand the health implications of international trade and trade agreements and to address relevant issues through policies and legislation.
• Work with competent international organisations to generate and share evidence on the relationship between trade and health.
Current WHO Actions: • Joint WTO-WHO trade and health country missions. • Regional trade and health workshops. • Scaled-up support to member states for developing national policies and strategies related to trade and health and structuring their requests to external development partners for capacity building in this area, focussing first on developing a trade and health diagnostic tool with the WTO and the World Bank to link diagnostic tool and country support to the Integrated Framework and Aid for Trade Initiative. • Legal reviews of the GATS and the SPS and TBT agreements from a health policy perspective and of trade and health notes for policy makers, extensively peer reviewed by international organisations and experts. • Publication of International Trade in Health Services and the GATS: Current Issues and Debates, edited by Chantal Blouin, Nick Drager, and Richard Smith (2005). • Publication of A Handbook of International Trade in Services, edited by Aaditya Mattoo, Robert M. Stern, and Gianni Zanini (2007). • Trade and health training courses (WHO-WTO), with training modules on the TRIPS Agreement and access to medicines, the GATS and trade in services, the SPS Agreement and food safety and infectious diseases. • World Bank Institute training courses on trade in services with a health module (trade in health-related services).
Notes: GATS = General Agreement on Trade in Services; SPS = Agreement on the Application of Sanitary and Phytosanitary Measures; TBT = Agreement on Technical Barriers to Trade; TRIPS = Agreement on Trade-Related Intellectual Property Rights; WHO = World Health Organization; WTO = World Trade Organization.
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Appendix 13-2: The House that GATS Built
Side Wall: Market access commitments
GATS (Services)
Front Wall: General obligations and disciplines
n tio t isa gh l a Ri er e b i s h t e L of vic de ork on Ser i Tra t ew a e t m v ser gula Fra Preo Re ral e t t a Back Wall: ltil Mu Exceptions
Floor: Dispute settlement
GATS Council
Note: GATS = General Agreement on Trade in Services.
Side Wall: National treatment commitments
GATS, FTAs, BITs
SPS, FTAs, GATS (agriculture)
Trade in health services
Trade in foodstuffs
access, quality
access, quality
Health implications direct opportunities (health risks, trade in bads) and indirect linkages (income and price effects)
Regulatory issues/ Flanking policies
Current mechanisms/ Capacity Capacityfor policy building coherence needs
Notes: BIT = bilateral investment treaty; FTA = free trade agreement; GATS = General Agreement on Trade in Services; GATT = General Agreement on Tariffs and Trade; SPS = Agreement on the Application of Sanitary and Phytosanitary Measures; TBT = Agreement on Technical Barriers to Trade; TRIPS = Agreement on Trade-Related Aspects of Intellectual Property Rights.
GATT, TBT, TRIPS; FTAs BITs
Negotiating What is issues related to trade being traded Offensive/ rules and (imports and defensive agreements exports) interests
Trade in health goods
Elements of study • Macroeconomic and trade environment • Priorities set out in poverty reduction strategy papers • Domestic health priorities
Performance, characteristics, approach, priorities
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Appendix 13-3: Diagnostic Tool for Trade and Health
Chapter 14
Explaining Compliance with G8 Health Commitments, 1996–2006 John J. Kirton, Nikolai Roudev, Laura Sunderland, and Catherine Kunz1
Can international institutions induce their members to commit to and comply with actions to address pressing global problems such as human health? This question has long been central to scholars and practitioners of international relations who want to know if international organisations, laws, and regimes affect the actions of their members and other autonomous states to achieve the ends they want and that the global community needs. It has become key for newer, informal, broadly oriented, summit-delivered, plurilateral institutions responding to the proliferating health challenges of a rapidly globalising world (Kirton and Trebilcock 2004). Among these soft law bodies, the G8 club of major market democracies stands at centre stage. It has made health a significant part of its annual summit agenda since 1996 (Hajnal 1999). It placed health as a priority theme at its St. Petersburg Summit in July 2006. Yet it has looked for help to long-established, formal, functionally focussed, ministerially guided, multilateral organisations such as the World Health Organization (WHO) (Abbott et al. 2000). Does this attention from the most powerful leaders of the most powerful countries, assembled in the informal institution they consider their own, make a desirable difference to the real health of people around the world? This question has given rise to a wide-ranging debate. On the one side stand those who assert that the G8 has done too little (Drohan 2005; Lewis 2005), done too much of the wrong thing (Labonté and Schrecker 2004; Labonté et al. 2004), or failed to deliver the good promises it has made (Foster 2002, 2003; ‘G8 Failed to Tackle the Toxic Politics of Drug Making and Selling’ 2003). On the other side stand those who argue that the G8 has already filled some gaps (Price-Smith 2001, 2002), has the potential to do much more (Savona and Oldani 2003), and is already delivering a new generation of health governance for a globalising world (Bayne 2005, 2001, 2000; Aginam 2004, 2005; Orbinski 2002). Within these competing schools of thought, the role of the established multilateral organisations of the United Nations system looms large. The first school of critics, which sees the G8 as a great fundraising failure, considers the G8’s proper role to be narrowly confined to raising massive amounts of new money to pass on,
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with few conditions attached, to the old UN organisations that have been unable to persuade their own members to provide the necessary sums (Drohan 2005; Lewis 2005). Acknowledging the failure of the old international organisations to deal adequately with the HIV/AIDS pandemic and arguing for a human right to health, these critics highlight the low level of financial commitments made by the G8 to provide antiretroviral therapy (ART) in developing countries. They also note the political lobbying of the U.S. government for the protection of the intellectual property rights of the world’s big pharmaceutical companies and the G8’s easy acceptance of a dominant America’s approach. Stephen Lewis (2005), an advocate formerly employed by the UN as Special Envoy on HIV/AIDS in Africa, has referred to this placement of intellectual property rights and international trade law above a human right to health as ‘mass murder by complacency’. A second cause he regularly refers to is the common attitude of racism shared by G8 members and others in a largely wealthy, white West. The third cause, he says, is the ‘thinly disguised neocolonial manipulation’ that maintained the G8’s ‘unbroken record of betraying their promises’ through to the Gleneagles Summit in 2005 (31, 149). A second school sees the G8 as having a much broader role, but failing to deliver the promising new directions now required to promote global health (Labonté and Schrecker 2004; Labonté et al. 2004; Labonte, Sanders, and Schrecker 2002). Here the G8’s failure to improve health outcomes in the face of a new generation of disease flows from the collateral damage caused by its members’ attachment to neoliberal principles in the economic and social policy areas that are vital in generating health. As Ronald Labonté and his colleagues (2004, 228) put it, ‘with respect to such an agenda that begins seriously to redress the human health and development catastrophes arising in the wake of contemporary globalization, the G8’s response can best, if disturbingly, be described as “fatal indifference”’. A third school locates the cause in institutional rather than ideological factors, notably the G8’s search as an informal, summit-level institution for short-term public relations success as part of its leaders’ domestic political management back home (Foster 2002, 2003; ‘G8 Failed’ 2003). This view of the G8 as an informal institutional failure asserts that the G8’s proper role goes beyond merely supporting the UN. But the G8’s focus on other issues and its narrow audience lead it to fail. Thus, in the lead-up to the 2002 Kananaskis Summit, John Foster (2002) concluded that ‘other priorities and photo opportunities may transcend the issue of follow-up and fulfilment’ on the G8’s global health file. A fourth school argues, in contrast, that the G8 is emerging as the global health governor of last resort, as a consequence of the poor performance of the old multilateral organisations and the high technical and economic capacity of G8 members (Price-Smith 2001, 2002). This school sees the UN organisations as having failed in addressing the world’s new health needs. It thus perceives the G8 as a useful supplement, gap filler, and insurance policy for an inadequate WHO. Andrew Price-Smith (2001, 178–179) concludes that the G8’s recent involvement in health stems from this weakening of the WHO, and from the G8’s ability to pick up the pieces from the failed global health institutions. He argues that the technical and
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economic capacity of the G8 makes it the most appropriate leader for the development of a badly needed ‘global disease containment regime’. A fifth school sees the G8 as the potential governor of globalisation in health as a whole (Savona and Oldani 2003). It argues that the G8 has already forged the new path for global health governance for an era where globalised markets threaten to overwhelm states. Paolo Savona and Chiara Oldani (2003, 100) claim that the G8 began by providing leadership as a consultative forum in the oil crises of the 1970s and has since become a global decision centre. The G8 is suited for global health governance because it adheres to the proper role of international institutions: ‘not to plunder nations’ residual sovereignty but to recover some shares of it from the market on behalf of national authorities’. A sixth school views the G8 as the emerging centre of 21st-century global health governance, due to the inclusive, multi-stakeholder model on which it is now based (Bayne 2000, 2001; Aginam 2004, 2005). Nicholas Bayne (2001, 34) attributes the G8’s success in dealing with health to its mobilisation of ‘intellectual, human, and financial resources from all available quarters—government, business, and NGOs [nongovernmental organisations] active in the field’. According to Bayne, the ‘most promising advance’ of the Okinawa Summit in 2000 came in health, with a call for a partnership to reduce the prevalence of AIDS, tuberculosis (TB), and malaria. This call was answered the following year at Genoa with the establishment of the Global Fund to Fight AIDS, Tuberculosis, and Malaria—a landmark initiative in its integration of governmental and nongovernmental actors. Its task-oriented collaboration between the private and public sectors represents the model for the future of global health governance (Orbinski 2002). These six schools largely share an assessment that the old international organisations for health have failed. They have not inspired their members to provide the necessary funding, coped with the HIV/AIDS pandemic and other emerging global health needs, pursued the proper principles, maintained a strong WHO, contained the role of the market in an age of globalisation, and brought all stakeholders and their resources in. Yet they differ on what the G8 should do in response, as they divide into three broad views about the proper relationship between the G8 and the international organisations of old. The first two schools identified above point to the need for G8 governance through the international organisations, with the G8 providing the money but not the neo-liberal ideology of the G8. The second two schools point to G8 governance without the international organisations, with the G8 serving as a supplement, gap filler, and insurance policy for an inadequate WHO, over a broad array of functions and approaches. And the final two schools suggest G8 governance against the international organisations, as only the G8 is designed, in anti-Westphalian fashion, to cope with globalisation and bring in all the necessary, different kinds of stakeholders. To advance this debate, this chapter provides a disciplined, detailed, evidencebased analysis of what G8 leaders can do to improve compliance with the health commitments they make at their annual summit and how their own G8 institutions, and those of the older 1940s UN galaxy can harm or help. It builds on an initial
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analysis of 30 cases of compliance with health commitments from 1996 to 2006, by adding an expanded analysis of 35 cases during the same time (Kirton, Roudev, and Sunderland 2007).2 It first assesses G8 performance in health across six governance functions that international institutions perform. It then examines whether its members comply with their collective commitments. It finally explores why they comply, asking how leaders can craft and embed innovative compliance catalysts that induce the sovereign states in the G8 to comply with their collective will. Here it focusses on whether the G8 leaders, through their use of their own plurilateral institutions and multilateral organisations such as the WHO, help or harm the compliance cause. This analysis shows that the G8 and its leaders have made a desirable difference in deliberating, setting directions, and deciding upon important actions to enhance global health. They have performed less well in consistently delivering the health commitments they have made. Yet at their annual summit G8 leaders themselves can craft their commitments in ways that contain particular catalysts proven to improve compliance with them during the following year. When they set a one-year timetable and ask the WHO to help, more compliance comes. Setting longer multiyear timetables or looking to their own G8 finance ministers’ forum or to multilateral organisations beyond the WHO does not help. In the latter case it actually harms. Thus G8 governance at the summit, through the most functionally focussed WHO, and without the other international organisations, is what works for the G8 in generating health compliance. G8 leaders would be well advised to build on this logic, by setting more one-year timetables and relying more on the WHO.
The Cadence of G8 Global Health Governance Since the onset of rapid globalisation in 1996, the G8 has emerged through several stages as an effective, high-performing centre of global health governance (Kirton and Mannell 2007; Kirton 2006a, 2005b). It has done so in domestic political management, deliberation, direction setting, decision making, delivery, and the development of global governance (see Appendix 14-1; Kirton 2005a). In 1996 and 1997, under first French and then American leadership, the G8 summits started discussing and deciding on global health issues in a substantial way. In 2000–01, under Japanese and Italian leadership, the G8 more than doubled its health deliberations and decisions, delivered these decisions to a very high degree, and mobilised new money to this end. In 2002–03, under Canadian and French leadership, the G8 set new directions and produced new peaks in its deliberative, directional, and decisional performance as well as in the development of G8-led global governance in health. In 2005, it took a step-level jump in the new money it mobilised for global health. This rapidly rising G8 performance has been led by almost all G8 countries, especially when each has served as host. Of particular note has been France as host in 1996 and above all in 2003, when it set new highs in the deliberative, direction setting, delivery, and development of G8 governance domains. These levels were not
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surpassed until Russia, as host in 2006, made infectious disease one of three priorities and established a new record for deliberation, direction setting, and deliberation. Effective action by the G8 has been driven by those forces highlighted by the concert equality model of G8 governance (Kirton 2005a, 2004, 1993, 1989). The most powerful has been the increasingly equal vulnerability of each G8 member to a new generation of infectious disease, as the early AIDS assault on America rapidly spread to all members made the G8’s newest member of Russia the G8’s most infected member and then proliferated across an Africa that had secured major attention and attendance at G8 summits since 2001. In response, the old organisations of the UN system, led by the WHO, have proven increasingly ineffective in mobilising their own members’ resources on the scale required or in meeting the targets and timetables they set. In contrast, the G8 countries possess the overall and specialised capabilities that are globally predominant, internally equal, politically interdependent, and collectively needed to combat the new diseases on a global scale. Their core, common, G8-grounded principles of open democracy and social advance bring them close to their newly democratic African partners and make them comfortable with the multi-stakeholder approaches most appropriate to combat the new generation of disease. From 2001 to 2005, the high political control at home of the popularly elected G8 leaders allowed the same seven individuals to come to an unprecedented five summits in a row, to meet with the same four core democratic African partners in the still constricted leaders-dominated G8 club. There they governed global health in the inclusive, interlinked, innovative way the G8 was designed for and that the world needs.
The Cadence of G8 Health Compliance Of the six G8 global governance functions, compliance does not correspond to the generally rising performance trend. Compliance here is conceived as the actions G8 member governments take to fulfil their G8 commitment within the year after it is made. Actions include speeches, new programmes, budgets, bureaucracies, and diplomatic initiatives (Kokotsis 1999; Daniels 1993). Health compliance from all G8 members from 1996 to 2005 averages +47.5 percent (on a scale from –100 percent to +100 percent).3 This is somewhat lower than compliance with G8 commitments across all issue areas during this time (Kirton and Kokotsis 2007). Health compliance has been in the positive range every year. Yet it varies widely from year to year, ranging from a low of +26 percent in 1998 and 2002 to a high of 80 percent in 2003. Between 1996 and 2006 there was a dual peak, with sudden, unsustained spikes to almost complete compliance in both 2000 (+77 percent) and 2003 (+80 percent) (see Appendix 14-1). Health compliance also varies widely by country, as follows: European Union +81 percent; United Kingdom +72 percent; Canada +66 percent; United States +63 percent; Japan +48 percent; France +45 percent; Germany +36 percent; Italy +21 percent; and Russia +4 percent (see Appendix 14-2). This pattern, similar
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to that for compliance with commitments across all issue areas, suggests that highly organised hard law institutions such as the EU may facilitate the G8’s health compliance task. Health compliance also varies even more widely by component issue, as follows: severe acute respiratory syndrome (SARS) +78 percent; aging +67 percent; TB +67 percent, biotechnology +66 percent; bioterrorism +56, Global Fund +56 percent; diseases (HIV, polio, malaria) +54 percent, drugs/medicine +45 percent; HIV/AIDS +44 percent; polio +39 percent; training +29 percent; development 0 percent (see Appendix 14-3). This pattern suggests that the G8 does better at compliance when the health commitment in question addresses an outbreak event, most directly affects citizens in G8 countries, or involves instruments directly under G8 government and country control. It also suggests that the G8 acts more easily within a biomedical model aimed at responding to acute outbreaks of diseases such as SARS than in a preventive way that embraces underlying healthcare systems, the socioeconomic determinants of health, and the root causes of underdevelopment as a whole.
Explaining Members’ Compliance: Agency, Institutionalisation, and Structure Why do the major power members of the G8 comply with their summit health commitments? Overall, compliance has been the most difficult dimension of G8 governance performance to explain (Kirton 2004; Kirton and Kokotsis 2003).4 Yet recent work in the finance and development field suggests that G8 compliance benefits from the agency of the G8 leaders themselves at their summit, reinforcing action from the G8 ministerial institution most functionally focussed on the subject, and the relative capabilities and vulnerabilities that constitute the structure of the international system (Kirton 2006b). Is the same true in the field of health, a much newer subject of G8 concern and one that lacks a G8 ministerial-level institution of its own? Agency As agents, G8 leaders, as an expression of their political will, consciously embed within their commitments particular catalysts that provide more specific guidance about how delivery should be done (see Appendix 14-4 for a list and definition of catalysts). An analysis of compliance with 46 G8 finance and development commitments from 1996 to 2005 found that two catalysts—priority placement and timetable—raised compliance, while no effect came from the others—target, remit mandate, money mobilised, specified agent, G8 body, and international institution (Kirton 2006a). To explore the impact of these compliance catalysts in the field of health, several catalysts were either dropped from the analysis (for lack of variation on the independent variable) or reconstructed for health-specific computational reasons: timetable was divided into one year or less and multi-year variants, international organisation was divided into the WHO (as the most functionally relevant established multilateral
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organisation) and other, and past promise was added to capture the important impact that iteration and continuity are hypothesised to have (Bayne 1999). As Appendix 14-5 shows, the analysis of 35 cases shows that a health commitment contains up to five such catalysts and as few as none. The most frequently employed across the initial 30 health commitments analysed were, in order, priority placement (13), specified agent (11), other international organisation (10), money mobilised (8), past promise (7), multi-year timetable (6), G8 body (6), and one-year timetable (4). The WHO was explicitly invoked in only two commitments, once in 2000 on HIV/ AIDS, malaria, and TB (where compliance came in at +100) and again in 2005 on polio (where the compliance score was +11 percent). From 2003 onward, the catalysts of priority placement and money mobilised have been the catalysts of choice. The effect of the catalyst variables on commitment compliance was formally tested in an initial study of 30 cases in a series of multivariate ordinary least squares (OLS) models. Because of the few degrees of freedom, due to the small sample size and many independent factors, it was not practical to incorporate the agency, institutionalisation, and structure variables used in earlier finance and development studies in a single grand model. Instead, each of the three categories of variables was tested separately. For the agency variables (the compliance catalysts), a full (unrestricted) OLS model of commitment compliance was tested first, and the best subset of catalysts (optimal nested sub-model) was selected using a forwardbackward search optimisation of Akaike information criteria (AIC) scores. The results generally agreed. In the restricted optimised model, two catalysts had highly significant, strong positive effects on compliance. The presence of a specific timetable of one year or less tended to increase compliance with that commitment by an average 0.65 compliance points. This variable is significant above the 99 percent confidence level. Its effect and direction remain robust among all considered models. Similarly, delegating some responsibility for the implementation of a health commitment to the WHO tended, on average, to improve compliance with that commitment by 0.55 compliance points. This variable is significant at the 92 percent confidence threshold. It should be considered as a significant explanatory factor of compliance, as its slightly deficient significance is an inevitable artefact of the small sample size (cf. Long 1997). The model has satisfactory explanatory power (adjusted R-squared of 0.147), particularly given the small sample size and the need to estimate the three groups of independent variables separately. To identify more specifically what caused compliance to differ from the overall level of compliance with all commitments in a given year, a further regression was conducted measuring the dependent variable by mean-adjusted compliance. This variable was constructed by removing the overall summit compliance for the given year from each individual commitment compliance score, thereby controlling for overall year-specific effects. Here the only significant variable identified both in the original (full) and optimised (nested) model is ‘other international organisation’. But it reduced rather than improved compliance, and did so by 5.9 compliance points. This variable is significant at the 94 percent confidence level.
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The same analysis was repeated on the larger set of 35 cases.5 In this expanded analysis, compliance was increased by setting a one-year timetable and, far more weakly, by specifying an implementing agent. Using summit-adjusted compliance scores, the impact of a one-year timetable is much reduced (to the point of disappearance), but the use of international organisations other than the WHO again exerts the same negative effect on compliance. A more detailed look at the effect of individual international institutions used as catalysts suggests no G8 or non-G8 body has an impact at accepted levels of probability (see Appendix 14-6). But the WHO comes closest, again with a positive impact on compliance. In all, these findings are consistent with the results of the initial 30-case analysis. But a larger study of more cases is clearly needed to confirm these causes with confidence and to specify more precisely how much and how individual international institutions and other catalysts exert their compliance enhancing or corroding effects. Institutionalisation A second potential cause of compliance is the conscious collective action of the ministers involved in G8 governance. Even when the leaders at the summit do not specifically embed in their commitment an instruction to a G8 institution to help implement their will, G8 institutions may autonomously seek to help. The most likely to act productively are the long-established G8 ministerial institutions with proud records of performance, often with popularly elected politicians as members, dense meeting schedules, and comprehensive, interconnected agendas. In the field of finance and development, compliance does indeed rise when the G8 finance ministers, in the oldest and the most powerful of the G8 ministerial institutions, act supportively (by remembering and repeating essentially the same commitment during the six months before and six months after the summit year, but letting the leaders do their own thing during the summit year itself (Kirton 2006b; Bergsten and Henning 1996). While G8 health ministers have only met once (in the spring of 2006), the G8 finance ministers have been active on health almost continuously since 1998. They were particularly engaged in 2000 and 2003, and the year after those two peaks. In 2000, 50 percent of the six finance ministerials dealt with health. In 2003, 75 percent of the four ministerials did. Both 2000 and 2003 had a higher than average number of compliance catalysts embedded in their health commitments (although 2001, 2004, and 2005 did as well). It is suggestive that 2000 and 2003 coincide with the same two years in which health compliance peaked. Yet a systematic look at whether the G8 finance ministers address the same issue as contained in their leaders’ health commitments shows that doing so has no effect on compliance, either before, during, or after the summit year. G8 leaders must look outside their current G8 institutional system for reinforcing help on the compliance front.
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Structure Are the efforts of G8 leaders to improve compliance assisted or overwhelmed by changes in the structure of the international system, as the relevant relative capabilities and vulnerabilities among G8 members change? In finance and development, a combination of increasingly equal vulnerability and capability among the G8 members did inspire finance ministers to remember and repeat such commitments, but did not directly increase compliance (Kirton 2006b). But in health there is no such indirect or a direct impact, either on the demand side of spreading vulnerabilities to pandemics or on the supply side of the relevant health capabilities that the G8 members possess.
Conclusion G8 leaders can act at their annual summit to improve compliance with the health commitments they make there. They can set a one-year timetable that corresponds with the period until their next summit comes along. They can also ask the WHO to lend a hand. Setting longer multi-year timetables or looking to their own G8 finance ministers forum or to multilateral organisations beyond the WHO will not help—and in the latter case will harm—G8 leaders’ ability to deliver the health decisions they collectively make. Thus international institutions make a desirable difference in improving global health governance, even if they are informal, plurilateral, generally oriented, leaders-level ones like the G8. But to do so they require careful, clever, action by leaders to craft their commitments in ways that contain the catalysts that help ensure compliance will come. Here G8 leaders must respect the one-year cadence of their own institution and look to the formal, multilateral, health-focussed WHO. The G8 can thus govern health through the international organisations, not by mobilising money or defining ideological directions for them, but by employing the existing capacity, credibility, and sense of ownership of the WHO alone as the premier organisation in the field. The G8 can govern without the international organisations by having its leaders set a strict one-year timetable for delivering their decisions and perhaps by specifying which agents are responsible for the implementation task. Yet there is no evidence that the G8 can govern against the international organisations by building a competitive G8-institutional system of its own, with different ideals and with more stakeholders more inclusively brought in.6 There is no case for asking the most well-established and frequently functioning ministerial body—the finance ministers—to deal with health. The question of holding more frequent health ministers meetings, following the Russian-hosted start in 2006, cannot be conclusively answered on the basis of the slender evidence available thus far. The first meeting of G8 health ministers, in Moscow in the spring of 2006, did not apparently raise compliance with the 2005 Gleneagles health commitments. They came in at +33 percent, the fourth lowest score in the ten years and below the
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ten-year average of +46 percent. Moreover, the average compliance score before 2001, when the annual ministerial meeting of the Global Health Security Initiative (which includes the G7 and Mexico) started, are virtually identical to that afterward. Yet a single meeting of an all-G8 health body is far too little a foundation on which to dismiss the value of such a forum.
Notes 1 The authors are grateful for the contributions of Ella Kokotsis, Lindsay Doyle, Hana Dhanji, Danielle Takacs, Heather Keachie, Jenevieve Mannell, Taleen Jakujyan, and Abby Slinger, and the analysts and senior experts of the G8 Research Group since 1996, for their analytical insight and research assistance. 2 This chapter analyses 35 cases of compliance with G8 health commitments from 1996 to 2006 by adding to the earlier analysis of 30 cases the five additional cases: one from 1997 on HIV, one from 2000 on aging, one from 2002 on immunisation, one from 2004 on bioterrorism, and one from 2005 on TB. 3 An inter-coder reliability check was done independently on compliance with the same commitment by two different trained compliance coders at two separate times: coder A in November 2005 and coder B in November 2006. They obtained 100 percent commonality in each of the eight G8 member countries they coded for compliance with the 2003 commitment on funding for polio eradication. 4 For general work on compliance with G7/8 commitments see Li Quan (2001), Mina Baliamoune (2000), Joseph Daniels (1993), and George von Furstenberg and Joseph Daniels (1991; 1992b; 1992a). For work by the G8 Research Group see John Kirton and Ella Kokotsis (2004); John Kirton, Ella Kokotsis, Gina Stephens, et al. (2004); John Kirton, Ella Kokotsis, and Diana Juricevic (2002a; 2002b); Ella Kokotsis (1995; 1999); Ella Kokotsis and Joseph Daniels (1999); and Ella Kokotsis and John Kirton (1997). 5 The 35 cases represented 27.7 percent of the 126 health commitments made by the G8 from 1996 to 2005. While these 35 cases do not represent a random sample of the 126 health commitments, an effort to minimise selection bias was made by first using all the health cases selected by the overall priority commitment identification of the G8 Research Group in its annual compliance assessment and then adding health cases that moved toward representing proportionately the number of health commitments made by G8 leaders at their summit by year and by issue area. Regression data is available from the authors upon request. 6 In all three approaches, the G8 leaders have largely failed to try to involve either G8 or nonG8 bodies, so conclusions about their success in doing so rest on fragile foundations.
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1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996
– – – – – – – – – – – – – – – – – – – – – NDA
G8RG score
0 0 0 0 0 0 0 0 5 0 0 0 1 0 0 0 0 0 0 0 0 0
0 0 0 0 1 1 0 4 1 1 2 2 7 2 3 7 9 3 3 2 2 14
Domestica Deliberativeb
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Directionalc Decisional Total Money commitments mobilised 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 6 0 – – – – – – – – – – – – – – – – – – – – – +43%
Deliveryd
Continued…
0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0
Developmente
270 Innovation in Global Health Governance
Appendix 14-1: An Overview of G8 Health Performance
A B+ NDA A+ NDA B– NDA NDA – A–
0 0 0 1 1 0 1 0 0 0 0.3
0 0 0 0 0 2 6 5 1 8 0.7 2
28
Directionalc
17 6 11 30 15 19 50 36 22 84 11
Domestica Deliberativeb
17
$3b
45.7%
Decisional Deliveryd Total Money commitments mobilised 10 0 +50% 5 0 +26% 5 0 +32% +77% 18 0 6 US$1.3 billion +38% 25 0 +26% 23 US$500 million +80% 14 US$3.3 billion +52% US$24 billion 14 +33% 64 US$4.4 billion 6 45.7% 0.5
0 0 0 0 1f 1 2 1 0 1
Developmente
Notes: – = No significant references to health were made by the G8 in that year; G8RG = G8 Research Group; NDA = no data available. Peak scores are in bold. a. Domestic political management includes mentions to G8 and health in the national policy addresses in the United States, Japan, the United Kingdom, and Canada. b. Deliberative includes references in documents, including the chair’s summary, issued at the annual summit. A unit is one paragraph. c. Directional includes references in summit chapeau or chair’s summary. A unit is one paragraph. d. Delivery combines the scores of the G8 Research Group and individual analysts. e. Development of global governance is the number of G8-centred health institutions created at the official and ministerial levels during the summit hosting year. Includes first G8 health ministers meeting in 2006. f. The establishment of the Global Fund to Fight AIDS, Tuberculosis, and Malaria.
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Average Average (since 1996)
G8RG score
Explaining Compliance with G8 Health Commitments, 1996–2006 271
Appendix 14-1: An Overview of G8 Health Performance, continued
+26%
0.00
0.00 +0.38
+0.25
2002 (6 of 25) = 24%
2002 Polio
2002 HIV 2002 Medicines
2002 Global Fund
2000 HIV, malaria, tuberculosis 2000 HIV, malaria, tuberculosis 2000 Drugs 2000 Aging
0.00
+0.43 +1.00 +1.00 +0.67
2000 (5 of 18) = 28%
+0.75
+77%
1999 HIV 1999 HIV, malaria, tuberculosis
2001 Development
+0.63 0.00
1999 (2 of 5) = 40%
2001 Global Fund
+32%
1998 HIV 1998 HIV 1998 Aging
+0.75
+0.33 +0.11 +0.33
1998 (3 of 5) = 60%
+38%
+26%
1997 HIV 1997 Development
2001 (2 of 6) = 33%
+1.00 0.00
1997 (2 of 10) = 20%
2000 Biotech
+0.43
+50%
1996 Drugs
Average +43%
Commitment 1996 (1 of 6) =17%
0
0 0
0
17%
0
0
0%
+1
0 +1 +1 +1
+80%
+1 0
+50
+1 +1 +1
+100%
+1 +1
+100
0
U.S. 0%
0
0 +1
0
+33%
0
0
0%
+1
+1 +1 +1 +1
+100%
+1 0
+50
0 –1 –
–50%
– 0
0%
+1
Japan +100
0
0 0
0
0%
0
+1
+50%
+1
0 +1 +1 +1
+80%
–1 0
–100%
0 –1 0
–33%
– +1
+100
+1
Germany +100
0
0 +1
0
+50%
0
+1
+50%
+1
– +1 +1 +1
+100%
+1 0
+50%
+1 +1 –
+100%
+1 +1
+100
+1
UK +100
– –1
–100
–
Italy –
0
– 0
0
+20%
0
+1
+50%
+1
– +1 +1 +1
+100%
+1 0
+50%
+1 +1 –
+1
– 0
0
0%
0
+1
+50%
+1
0 +1 +1 0
+60%
+1 0
+50%
–1 –1 –
+100% –100%
+1 –1
–100
0
France 0%
+1
0 +1
0
+67%
0
+1
+50%
+1
+1 +1 +1 +1
+100%
+1 0
+50%
+1 +1 0
+67%
+1 –1
–100
0
Canada 0%
0
– 0
0
0%
0
+1
+50%
–1
0 – +1 –1
–25%
0 0
0%
–1 –1 –
–100%
– –
–
–
Russia –
–
0 –
–
AS
TJ LS JM
G8RG G8RG
G8RG
TJ G8RG G8RG CK
JM DT
DT DT G8RG
LD G8RG
G8RG
Source
Continued…
+50%
–
–
–
–
+1 +1 +1 +1
+100%
– –
–
+1 +1 –
+100%
– –
–
–
EU –
272 Innovation in Global Health Governance
Appendix 14-2: G8 Health Compliance by Commitment and Country, N=35
+33%
+0.25
+0.29 +0.33 +0.11 +0.67
2005 (5 of 14) = 36%
2005 Disease
2005 Training 2005 Global Fund 2005 Polio 2005 Tuberculosis
0 +1 +1 +1
0
+60%
+1 +1 +1
+100%
+48%
16/33
+1 +1 –1 +1
+1
+60%
–1 +1 0
0%
+1 +1 +1 +1 0 +1
+83%
Japan 0 +1
+36%
12/33
0 0 +1 0
–
+25%
+1 +1 +1
+100%
+1 0 +1 0 0 +1
+50%
Germany 0 0
+72%
23/32
–1 0 +1 +1
–
+25%
+1 +1 +1
+100%
+1 +1 +1 +1 0 +1
+83%
UK +1 +1
+45%
14/31
+1 0 –1 0
–
0%
+1 0 –1
0%
+1 +1 +1 +1 0 +1
+83%
France 0 +1
+21%
6/29
– –1 –1 0
–
–67%
+1 +1 –1
+67%
+1 +1 +1 +1 0 +1
+83%
Italy –1 0
+66%
23/35
0 0 +1 +1
–1
+20%
+1 +1 +1
+100%
+1 +1 +1 +1 +1 +1
+100%
Canada +1 +1
04%
1/27
– +1 –1 +1
+1
+50%
–1 –1 +1
–33%
+1 +1 +1 0 – –
+75%
Russia 0 –
+81%
17/21
+1 +1 +1 +1
–
+100%
+1 0 +1
+67%
+1 +1 +1 +1 0 –
+80%
EU +1 –
AS CK G8RG G8RG HD
G8RG CK G8RG
LD G8RG LD LS LS LS
Source HK G8RG
Notes: Global Fund = Global Fund to Fight AIDS, Tuberculosis, and Malaria; SARS = severe acute respiratory syndrome. Compliance coders in alphabetical order: AS = Abby Slinger, CK = Catherine Kunz, DT = Danielle Takacs, G8RG = G8 Research Group, HD = Hana Dhanji, HK = Heather Keachie, JM = Jenevieve Mannell, LD = Lindsay Doyle, LS = Laura Sunderland, TJ = Taleen Jakujyan. The average was determined by averaging the yearly averages. All years are weighted equally, despite the number of commitments for each year.
22/35
+0.56 +0.56 +0.44
2004 HIV 2004 Bioterrorism 2004 Polio
+1 +1 +1 +1 0 +1
+83%
+63%
+52%
2004 (3 of 14) = 21%
+46%
+1.00 +0.89 +1.00 +0.78 +0.13 +1.00
2003 Aging 2003 Global Fund 2003 Polio 2003 SARS 2003 Medicines 2003 Disease
Average
+80%
2003 (6 of 23) = 26%
U.S. +1 0
Ratio
Average +0.33 +0.57
Commitment 2002 Immunisation 2002 Biotechnology
Explaining Compliance with G8 Health Commitments, 1996–2006 273
Appendix 14-2: G8 Health Compliance by Commitment and Country, N=35, continued
+44% +1.00 +0.33 +0.11 +0.63 0.00 +0.56 +45% +0.43 +1.00 +0.38 +0.33 +0.13 +54% 0.00 +0.43 +1.00 +1.00 +0.25 +56% +0.75
HIV/AIDS (6) 1997 1998 1998 1999 2002 2004 Drugs/Medicines (5) 1996 Drugs 2000 Drugs 2002 Medicines
2002 Immunisation
2003 Medicines Diseases: HIV, polio, malaria, tuberculosis (5) 1999 HIV, polio, tuberculosis 2000 HIV, malaria, tuberculosis 2000 HIV, malaria, tuberculosis 2003 HIV, malaria, tuberculosis
2005 Disease Global Fund (4) 2001
Average +39% 0.00 +1.00 +0.44 +0.11
Commitment Polio (4) 2002 2003 2004 2005
0 +40% 0 0 +1 +1 0 +50% 0
+1
+83% +1 +1 +1 +1 0 +1 +40% 0 +1 0
U.S. +75% 0 +1 +1 +1
0 +80% 0 +1 +1 +1 +1 +50% 0
0
–20% – 0 –1 +1 0 –1 +60% +1 +1 +1
Japan 00% 0 +1 0 –1
0 +50% 0 0 +1 +1 – +25% +1
0
–20% – 0 –1 –1 0 +1 +40% +1 +1 0
Germany +75% 0 +1 +1 +1
0 +67% 0 – +1 +1 – +50% +1
+1
+83% +1 +1 +1 +1 0 +1 +80% +1 +1 +1
UK +75% 0 +1 +1 +1
0 +67% 0 – +1 +1 – +50% +1
0
+100% +1 +1 +1 +1 – +1 +20% 0 +1 0
France –25% 0 +1 –1 –1
0 +50% 0 0 +1 +1 – +50% +1
–1
00% – –1 –1 +1 – +1 00% – +1 0
Italy –25% 0 +1 –1 –1
+1 +40% 0 +1 +1 +1 –1 +75% +1
+1
+83% +1 +1 +1 +1 0 +1 +80% 0 +1 +1
Canada +75% 0 +1 +1 +1
0 +100% – +1 +1 – – +100% –
+1
+75% – +1 +1 – 0 +1 +67% – +1 –
EU +100% – +1 +1 +1
Continued…
– +33% 0 0 – – +1 +75% +1
0
–75% – –1 –1 0 – –1 +33% – +1 0
Russia +25% 0 +1 +1 –1
274 Innovation in Global Health Governance
Appendix 14-3: G8 Health Compliance by Issue Area and Country, N=35
0.00 +66% +0.75 +0.57 +67% +0.33 +0.67 +1.00 +29% +0.29 +78% +0.78 +56% +0.56 +67% +0.67 +50%
2001 Biotechnology (2) 2000 2002 Aging (3) 1998 2000 2003 Training (1) 2005 SARS (1) 2003 Bioterrorism (1) 2004 Tuberculosis (1) 2005
Average
0 +50% +1 0 +100% +1 +1 +1 00% 0 +100% +1 +100% +1 +100 +1
U.S. 0 +1 +1 +50% +1 0 +100% +1 +1 +100% – +1 +1 +100% +1 +100% +1 +100% +1 +100 +1
Japan 0 +1 +1 00% 0 0 +50% +1 0 +67% 0 +1 +1 00% 0 00% 0 +100% +1 +100 0
Germany 0 0 0 +50% +1 0 +100% +1 +1 +100% – +1 +1 –100% –1 +100% +1 +100% +1 +100 +1
UK 0 +1 0 +50% +1 0 +100% +1 +1 +100% – +1 +1 +100% +1 +100% +1 00% 0 00% 0
France 0 +1 0 –50% –1 0 +50% +1 0 +50% – 0 +1 – – +100% +1 +100% +1 00% 0
Italy +1 +1 –1 –50% –1 0 +100% +1 +1 +67% 0 +1 +1 00% 0 +100% +1 +100% +1 +100% +1
Canada +1 +1 0 –50% –1 0 –100% –1 – 00% – –1 +1 – – 00% 0 –100% –1 +100% +1
Russia 0 +1 +1 00% – – – – – +100% – +1 +1 +100% +1 +100% +1 00% 0 +100% +1
EU – +1 +1 – –
Notes: Global Fund = Global Fund to Fight AIDS, Tuberculosis, and Malaria; SARS = severe acute respiratory syndrome. The average is the average of the average issue area scores. All issue areas are weighted equally, despite the number of commitments of each issue area.
Average +0.25 +0.89 +0.33 00% 0.00
Commitment 2002 2003 2005 Development (2) 1997
Explaining Compliance with G8 Health Commitments, 1996–2006 275
Appendix 14-3: G8 Health Compliance by Issue Area and Country, N=35, continued
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Appendix 14-4: Compliance Catalysts Defined 1. Priority Placement refers to the presence of the commitment (or a similarly worded commitment) in the communiqué chapeau (introduction or preamble), summary, or chair’s statement to deliberately give temporal primary and prominence, emphasis through repetition, or the direct authority of leaders to documents devised elsewhere. 2. Target is a specific, numerical, measurable target or goal (e.g., We will reduce greenhouse gases by 50 percent). Terms such as ‘reduce’ or ‘increase’ usually accompany a measurable target. Terms such as ‘continue to fight against’ are not considered targets. 3. Timetables: One Year or Less. A timetable is a specific target date that provides the precision and obligation featured by legalised liberal institutionalism. Timetables include: a. an exact date, year, or season (autumn, summer, spring, winter) that is specified by the G8 as the deadline for the commitment. Terms include ‘over the year ahead’, ‘in the coming year’, ‘this year’, or ‘before the next summit’; b. a specified meeting in another forum that is not the G8 (such as the United Nations General Assembly or the meeting of a Conference of the Parties) or a specified G8 ministerial-level meeting; and c. timetables agreed to in other forums, which are reaffirmed in the commitment and are stated explicitly or implicitly (e.g., ‘the timetables agreed at the end of the Uruguay Round’ or ‘by 1 January, as decided at the United Nations General Assembly’). Terms such as ‘as soon as possible’ or ‘urgently’ are not coded as using a timetable. 4. Timetables: Multi-year. A timetable longer than one year. 5. Specified Agency refers to the identification of national, intergovernmental, or other agents responsible for implementing the commitment. It includes: a. any body, country, person, etc., specifically designated to take charge of a commitment as a representative of the G8; b. instances when the G8 commits itself along with ‘all other countries’, ‘the international community as a whole’, ‘our partners’, ‘civil society’, specified countries, etc.; and c. instances when the G8 commits to work with others to do something and when the G8 ‘calls on all countries’ or pledges to work to enhance international efforts to achieve a target. While the G8 alone may still be responsible for putting the most effort behind such initiatives, these types of key terms suggest a larger base of action than just the
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G8 alone. The agent is often a G8-centred ministerial or official-level institution or an international institution, and is thus coded in those categories, rather than as an agent. 6. Remit Mandate is a requirement to report back to the summit. Such mandates provide the built-in iteration, repeated games, and so-called long shadow of the future featured by several theories of international cooperation. A commitment to re-examine an issue at a ministerial meeting, rather than at the actual summit, is coded as the use of a timetable, not a remit mandate. 7. Money Mobilised refers to new money promised at the summit to implement G8 commitments, as highlighted by classic theories of international organisation. It includes: a. money committed by the G8; b. money committed by another agency, group, institution, etc.; and c. reaffirmations of previously committed money. A commitment to provide the ‘necessary’, ‘sufficient’, or ‘proficient’ resources or ‘necessary funding’, etc., for a target is also considered money mobilised. Also included are participation at a donors conference and ‘closing the resource gap’. ‘Providing aid’ or ‘assistance’ is not counted as money mobilised. 8. G8-Centred Body: Other G8 Body refers to any mention of a G8-centred or G8-created body or institution (other than the G7 finance ministers or G20 finance ministers and central bank governors) at the ministerial or official level. 9. International Institution: Other International Organisation refers to any mention of an international institution (other than the World Health Organization), its directors or staff, activities, meetings, initiatives, or programmes. 10. International Institution: World Health Organization refers to mentions of or instructions to the World Health Organization, its directors or staff, activities, meetings, initiatives, or programmes. 11. Past Promise reaffirms, continues, or presses ahead with a past commitment by referring explicitly to such a promise from the past.
Commitment 1996 Drugs 1997 HIV 1997 Development 1998 HIV 1998 HIV 1998 Aging 1999 HIV 1999 HIV, polio, tuberculosis 2000 HIV, malaria, tuberculosis 2000 HIV, malaria, tuberculosis 2000 Drugs 2000 Aging 2000 Biotechnology 2001 Global Fund 2001 Development 2002 Polio 2002 HIV 2002 Medicines 2002 Global Fund 2002 Immunisation 2002 Biotechnology 2003 Aging 2003 Global Fund 2003 Polio
Individual score +0.43 +1.00 0.00 +0.33 +0.11 +0.33 +0.63 0.00 +0.60 +1.00 +1.00 +0.67 +0.75 +0.75 0.00 0.00 0.00 +0.38 +0.25 +0.33 +0.57 +1.00 +0.89 +1.00
Overall score +36.0 +12.8 +12.8 +0.32 +0.32 +0.32 +0.44 +0.44 +0.81 +0.81 +0.81 +0.81 +0.81 +0.46 +0.46 +0.36 +0.36 +0.36 +0.36 +0.36 +0.36 +0.51 +0.51 +0.51
Overall health score +0.43 +0.50 +0.50 +0.26 +0.26 +0.26 +0.32 +0.32 +0.77 +0.77 +0.77 +0.77 +0.77 +0.38 +0.38 +0.26 +0.26 +0.26 +0.26 +0.26 +0.26 +0.80 +0.80 +0.80 Catalysts 1 1 1 3 1 0 1 1 0 4 5 0 2 5 1 3 0 2 4 0 0 1 4 2
Priority placement 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 1 1 1 Target 0 0 0 1 0 0 0 0 0 1 1 0 0 0 0 1 0 0 1 0 1 0 1 1
Timetable (< 1 year) 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 0 Continued…
Timetable (multi-year) 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 1 0 0 0 0 0 0 0 1
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Appendix 14-5: G8 Health Commitments with Compliance Catalysts, 1996–2005, N=35
Overall score +0.51 +0.51 +0.51 +0.55 +0.55 +0.55 +0.65 +0.65 +0.65 +0.65 +0.65
Overall health score +0.80 +0.80 +0.80 +052 +052 +052 +0.33 +0.33 +0.33 +0.33 +0.33 Catalysts 1 2 1 1 3 0 1 4 1 3 4 70
Priority placement 1 1 1 1 1 0 1 1 0 0 1 13/35 Target 0 0 0 0 0 0 0 0 0 0 0 8/35
Timetable (< 1 year) 0 0 0 0 1 0 0 0 0 0 0 4/35
Timetable (multi-year) 0 0 0 0 0 0 0 0 0 1 1 6/35
Continued…
Notes: Global Fund = Global Fund to Fight AIDS, Tuberculosis, and Malaria; SARS = severe acute respiratory syndrome. The health issue area includes all references to health, public health, aging, infectious disease, the Global Fund to Fight AIDS, Tuberculosis, and Malaria, health-related international organisations, drug use, drug conventions, pharmaceuticals, medications, water, biotechnology, the human impact of bioterrorism, and anything that directly affects human health and well-being. It excludes references to food crops, agriculture, famine, and biological weapons, unless human health or disease outbreak is directly referenced in the commitment.
Commitment 2003 SARS 2003 Medicines 2003 HIV, malaria, tuberculosis 2004 HIV 2004 Polio 2004 Bioterrorism 2005 Disease 2005 Global Fund 2005 Training 2005 Polio 2005 Tuberculosis Totals
Individual score +0.78 +0.13 +1.00 +0.56 +0.44 +0.56 +0.25 +0.33 +0.29 +0.11 +0.67
Explaining Compliance with G8 Health Commitments, 1996–2006 279
Appendix 14-5: G8 Health Commitments with Compliance Catalysts, 1996–2005, N=35, continued
Commitment 1996 Drugs 1997 HIV 1997 Development 1998 HIV 1998 HIV 1998 Aging 1999 HIV 1999 HIV, polio, tuberculosis 2000 HIV, malaria, tuberculosis 2000 HIV, malaria, tuberculosis 2000 Drugs 2000 Aging 2000 Biotechnology 2001 Global Fund 2001 Development 2002 Polio 2002 HIV 2002 Medicines 2002 Global Fund 2002 Immunisation 2002 Biotechnology 2003 Aging 2003 Global Fund 2003 Polio
Remit 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Money mobilised 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 1 1
Agent specified 0 0 1 0 0 0 0 0 0 1 1 0 0 0 1 0 0 1 0 0 0 0 1 0
International institutions WHO Other 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 1 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 G8 body 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 1 0 Continued…
Past promise 0 0 0 1 0 0 1 1 0 0 1 0 0 1 0 0 0 1 1 0 0 0 0 0
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Appendix 14-5: G8 Health Commitments with Compliance Catalysts, 1996–2005, N=35, continued
Remit 0 0 0 0 0 0 0 0 0 0 0 0/35
Money mobilised 0 0 0 0 1 0 0 1 0 1 0 8/35
Agent spefified 0 1 0 0 1 0 0 1 1 1 0 11/35
G8 body 0 0 0 0 0 0 0 1 0 0 1 6/35
Past promise 0 0 0 0 0 0 0 0 0 0 0 7/35
Notes: Global Fund = Global Fund to Fight AIDS, Tuberculosis, and Malaria; SARS = severe acute respiratory syndrome. The health issue area encompasses all references to health, public health, aging, infectious disease, the Global Fund to Fight AIDS, Tuberculosis, and Malaria, health-related international organisations, drug use, drug conventions, pharmaceuticals, medications, water, biotechnology, the human impact of bioterrorism, and anything that directly affects human health and well-being. It excludes references to food crops, agriculture, famine, and biological weapons, unless human health or disease outbreak is directly referenced in the commitment.
Commitment 2003 SARS 2003 Medicines 2003 HIV, malaria, tuberculosis 2004 HIV 2004 Polio 2004 Bioterrorism 2005 Disease 2005 Global Fund 2005 Training 2005 Polio 2005 Tuberculosis Totals
International institutions WHO Other 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 1 0 1 2/35 10/35
Explaining Compliance with G8 Health Commitments, 1996–2006
Appendix 14-5: G8 Health Commitments with Compliance Catalysts, 1996–2005, N=35, continued
281
Commitment 1996 Drugs 1997 HIV 1997 Development 1998 HIV 1998 HIV 1998 Aging 1999 HIV 1999 HIV, malaria, tuberculosis 2000 HIV, malaria, tuberculosis 2000 HIV, malaria, tuberculosis 2000 Drugs 2000 Aging 2000 Biotechnology 2001 Global Fund 2001 Development 2002 Polio 2002 HIV 2002 Medicines 2002 Global Fund 2002 Immunisation 2002 Biotechnology 2003 Aging 2003 Global Fund 2003 Polio
Score +0.43 +1.00 0.00 +0.33 +0.11 +0.33 +0.63 0.00 +0.60 +1.00 +1.00 +0.67 +0.75 +0.75 0.00 0.00 0.00 +0.38 +0.25 +0.33 +0.57 +1.00 +0.89 +1.00
Total bodies 1 0 0 1 1 0 0 0 0 2 1 0 1 2 1 0 0 0 1 0 0 0 1 0 UN 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0
International organisations UNAIDS WHO CAC GPEI 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 STB 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Continued…
G8-centred bodies TSI GF HM 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0
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Appendix 14-6: Specific International Organisations and G8 Bodies, by Commitment, N=35
Score +0.78 +0.13 +1.00 +0.56 +0.44 +0.56 +0.25 +0.33 +0.29 +0.11 +0.67
Total bodies 0 0 0 0 0 0 0 2 0 1 1 UN 0 0 0 0 0 0 0 1 0 0 0
International organisations UNAIDS WHO CAC GPEI 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 STB 0 0 0 0 0 0 0 0 0 0 1
G8-centred bodies TSI GF HM 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1
Notes: CAC = Codex Alimentarius Commission; GF = Global Fund to Fight AIDS, Malaria, and Tuberculosis; GPEI = Global Polio Eradication Initiative; HM = G8 health ministers; SARS = severe acute respiratory syndrome; STB = Stop TB Partnership; TSI = Therapeutic Solidarity Initiative; UN = United Nations (includes references to General Assembly and the secretary general, meetings, and summits); UNAIDS = Joint United Nations Programme on HIV/AIDS; WHO = World Health Organization.
Commitment 2003 SARS 2003 Medicines 2003 Disease 2004 HIV 2004 Polio 2004 Bioterrorism 2005 Disease 2005 Global Fund 2005 Training 2005 Polio 2005 Tuberculosis
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Chapter 15
Global Health Initiatives: A Healthy Governance Response? Caroline Khoubesserian
The expansion of global health initiatives in recent years is a significant sign of innovation in global governance. These multi-level initiatives, such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria and the Stop TB Partnership, have emerged as an innovative type of mechanism to assist those developing countries at the forefront of the challenge to eradicate a host of infectious diseases (see Table 15‑1). No longer are bilateral aid programmes the lone or preferred solution for health concerns in the global economic South. This resort to global health initiatives reflects both an increased commitment to tackle health issues on a global basis and a recognition that the conventional template of governance tools requires a redesign. The catalysts for new thinking and types of action for the health dossier, now considered a global public good, are the spread of the HIV/AIDS crises and the looming threat of a global avian influenza pandemic.1 These challenges demand that the structures of global health governance be ramped up in an unanticipated fashion. Traditional approaches still matter—and a number of donor governments have refined their programmes of official development assistance (ODA) in an attempt to be more responsive to this set of problems. However, while necessary, this adjustment is no longer perceived to be sufficient. The resulting deficit is being filled, at least in part, by global health initiatives, which have moved into a prominent position in defining conceptually and tackling practically the issues on the front lines of the health governance crisis. This is not to say that the traditional and the innovative means of addressing health governance are at odds with each other. On the contrary, they can often be complementary. Therefore, to understand the emergent global health governance system better, an examination of both the rise of global health initiatives and current ODA strategies is necessary. How these two mechanisms correspond to the health needs of developing countries will allow a better appreciation of how responsive the current governance system is to global health challenges. To examine this interface, this chapter outlines the global health context, which tends to focus on disease eradication. It describes the salient features of global health initiatives and the rationale behind their recent expanded profile, as well as their strengths and weaknesses as innovative means to address global health problems. These campaigns will be compared with the ODA strategies of the United Kingdom,
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the United States, and Canada with regard to health governance issues. This dual analysis will provide a valuable framework for measuring the response of the global governance system to current health challenges. From this analysis the chapter assesses what features stand out in terms of their impact on global health governance and how these components can be incorporated to improve the system. In today’s globalised world, health governance issues, in particular the outbreak of infectious disease, have moved beyond the bounds of the technical experts. This leads to complex interlinkages as well as oversimplification. Concerns about pandemics and their links to economic and security issues are all over the news and other media. Examples include coverage on the rising cases of avian influenza (CBC News 2008), the 7 November 2005 issue of Time Magazine issue on global health (‘How to Save a Life: A Special Report on the World’s Most Dangerous Diseases— and the Heroes Fighting Them’); the diary of Jeffrey Sachs and Angelina Jolie on MTV (2007) highlighting the problems of HIV/AIDS in Africa, articles such as The Economist’s ‘Bird Flu Flares Up Again in Asia’ (2007), and the many headlines announcing the multi-country outbreaks of severe acute respiratory syndrome (SARS) and a corresponding downturn in the tourism business in 2003. Indeed, packaging details about specific diseases into popularized formats is important for informing the public and mobilising action. But it generally misses the complexities Table 15-1: Global Health Initiatives with Annual Budgets Global Health Initiative PolioPlus, Rotary International Global Fund to Fight AIDS, Tuberculosis, and Malaria Clinton Foundation HIV/ AIDS Initiative
Bill and Melinda Gates Foundation
WHO ‘3 by 5’ initiative International AIDS Vaccine Initiative
GAVI
Stop TB Partnership Smallpox initiative
Disease Focus Polio
Founded 1985
HIV/AIDS, malaria and tuberculosis HIV/AIDS
2001
HIV/AIDS, malaria, tuberculosis, and other infectious diseases HIV/AIDS HIV/AIDS
2000
Hepatitis B, yellow fever, Haemophilis influenzae type b, and other diseases Tuberculosis Smallpox
2003
2001
2003 1996
Budget US$135 000 000 between 2002 and 2005 US$4 721 953 738 between 2001 and 2005 US$56 008 771 2004 (foundation’s annual expenses but not specific to initiative) US$447 003 000 2004
N/A US$380 000 000 to date US$654 000 000 2005 to 2009 US$3 592 347
2000 N/A 1967–1980 US$300,000,000
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and omits a balanced analysis of overall health challenges. Excessive mediatisation of disease problems is counterproductive to the overall health picture. It can incite fear in the general population, who in turn demand a targeted, quick fix and not necessarily a comprehensive response. Also, glossy campaigns of disease eradication compete against each other for attention and resources. Overall, issues pertinent to basic health lose out to issue-specific initiatives. Global health initiatives mirror this increasing fixation on disease outbreak. They typically centre on a single disease that affects the developing world and campaign to raise resources to eliminate it. These attempts to eradicate infectious diseases certainly have positive aspects. But they are targeted, ‘vertical’ programmes meant to contain one specific problem among a host of growing challenges.2 Questions must be asked if a response to infectious diseases in the developing world is to fit into a larger comprehensive system. Do the vertical programmes complement the broader ODA strategies for health problems? Do these concerns help or distract development agencies from coping with other emergent health problems? If unaccompanied by a more comprehensive and coherent approach, this increased sensitivity to disease eradication would seem more akin to crisis management than to strategic agenda setting for preparing for and preventing global health problems. Conversely, however, the reconfiguration of ODA strategies as well as an embrace of global health initiatives in response to a specific challenge could signify a maturation process of how governance is performed. The way could be opened toward a hybrid approach to addressing health needs that is intended to be proactive and complete. The area under discussion in this chapter—whether the rise of global health initiatives complements an equally responsive set of ODA strategies on global health challenges—is a snapshot of two larger questions: What is the current status of the global health governance system? And is it adequate to meet both traditional and unanticipated challenges? There are many components to this system and many angles from which to examine it. This chapter focusses on only one crucial theme: the connection between the use of ODA programmes and the use of global health initiatives as tools for addressing issues of health governance. This theme encompasses many important facets of global health governance, including the prioritisation of donor countries concerning the health challenges facing a large majority of the world’s population and the means they bring to bear to try to resolve those challenges.
What Are Global Health Initiatives? Well-recognised global health initiatives have recently moved into the spotlight as leaders for global health issues. These include the Stop TB Partnership (1998), Roll Back Malaria (2000), the Global Fund to Fight AIDS, Tuberculosis, and Malaria (2001), the Clinton Foundation HIV/AIDS Initiative (2001), the World Health Organization’s (WHO) ‘3 by 5’ initiative (2003), the Bill and Melinda Gates Foundation Grand Challenges in Global Health (2003), the rejuvenation of the Carter
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Center Guinea Worm Eradication Program (2005), and GAVI (formerly the Global Alliance for Vaccines and Immunisation; 2000). The precursors to such mechanisms were the WHO’s Smallpox Eradication Programme (1967), Rotary International’s PolioPlus campaign (1985), and the International AIDS Vaccine Initiative (IAVI; 1996). This list indicates the proliferation of global health initiatives in scope and targeting. Conceptually, these initiatives are funds that focus on one specific disease or set of diseases and concentrate their efforts—the raising and disbursement of funds—on eradicating those diseases. They set out guidelines to encourage the development of projects where they are most needed based on an analysis of the spread of the infectious disease and the existing response to it (or lack thereof). The WHO views global health initiatives as working alongside public-private partnerships (PPP) to set out a global strategy and inject additional resources into the system to target specific diseases. As such this instrument is regarded positively as being ‘one of the benefits of globalization’ (WHO 2008). Global health initiatives are commonly created by international organisations. However, one of their most striking aspects is that they can also be established by large private foundations led by well-recognised international figures. Indeed, these are initiatives that have the capacity and funds to have a deep global impact. Those global health initiatives mentioned above, and a number of other initiatives, all have in common the creation of a focal point for actors to mobilise and contribute significant resources to the eradication of a particular disease. An initiative as a vehicle for rallying these actors elevates the issue above individual government ministries, states, and international agencies, breaking down silos so that individual and autonomous projects can become part of a larger global strategy. Such attributes, in addition to the sheer intensity of their approach, indicate that these initiatives must be taken seriously as innovative instruments of global governance. Such global campaigns or network-like structures are not exclusive to health initiatives; a mixture of global actors have come together in the past to cooperate on other global issues. These include the International Campaign to Ban Landmines that formed in 1992 and won the Nobel Peace Prize in 1997, the 2000 Jubilee Debt Campaign launched in 1996, and the relief efforts after the tsunami in the Indian Ocean on 26 December 2004. Generally, these multi-level campaigns were established because there was an understanding that the problems they addressed, which were cross-sectoral and cross-border in nature, required a collaborative effort involving many actors outside traditional mechanisms. In terms of process, these campaigns went around the established institutions. In terms of composition they were composed of both state and non-state actors. This rise in these complex global initiatives does not necessarily indicate that states are failing to respond, but rather that traditional governance mechanisms cannot always satisfy the novel and all-encompassing global dimensions of emerging problems alone (Dodgson, Lee, and Drager 2002, 19). Typically these initiatives have the support of significant resources both from governments and private sources such as foundations and private citizens. Global health initiatives
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have established some of the largest budgets among such campaigns and have been found to be sustainable over time. Some of the budgets are even comparable to the ODA budgets of rich countries. Support from the participating industrialised countries comes directly from their ODA budgets. Thus, far from being detached, the global initiative mechanism is recognised and linked to the ODA policies of these countries. This brings both strengths and weaknesses to the overall system of global health governance. Why Global Health Initiatives? The development and increase of global health initiatives in the new millennium are attributable to a series of pushes and pulls at the international level that have been accentuated over the past few decades. These factors provide an explanation of why an increased response concerning health issues was necessary, as well as why a global health mechanism in particular, as opposed to the traditional ODA mechanism, was ideal for taking on the challenge in the developing world. These factors and changes also explain how the need to respond to infectious diseases was placed as a priority on the global agenda. The most direct push for global health initiatives is the challenge of an unusually large increase in new infectious diseases. According to one report, ‘since 1973, more than 30 previously unknown diseases associated with viruses and bacteria have emerged. Examples include: Ebola virus (1977); Legionnaires’ disease (1977); E. coli 0157:H7-associated hemolytic uremic syndrome (1982); HIV/AIDS (1981); Hepatitis C (1989); variant Creutzfeldt-Jakob disease (1996); and H5N1 Influenza A or avian flu (1997) … As well, some known infectious diseases, such as tuberculosis, have re-emerged in vulnerable populations’ (National Advisory Committee on SARS and Public Health 2003, 2). Such a spike in infectious disease around the world should naturally have a corresponding intensified global response. Since specialised international campaigns to eradicate disease were reasonably successful with smallpox and polio, the global governance system could build on this model to confront the emergence of new diseases. Another reason that global health initiatives are now over preferred mechanism in comparison to traditional responses is the inadequacy of development agencies during the 1980s and ’90s in recognising the urgency of health problems. For many years ODA strategies did not place health at the top of their priority list when assisting developing countries while, in retrospect, problems galloped at an intense pace. As Sachs and others highlighted in the 1990s, aid agencies were failing in terms of addressing malaria, HIV/AIDS, and other health issues. According to him (2005, 202), those implementing development policy knew ‘very little about public health, and traditionally they pay almost no attention to whether health spending in their client countries is $10 or $100 or $1,000 or more per person’. Thus, in the 1990s hundreds of millions of dollars annually were earmarked to meet the challenge of infectious diseases, whereas now as much as US$8 billion is spent on HIV/AIDS
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alone each year (Sachs 2005, 196; Rockefeller Foundation 2004, 5). Health simply was not considered an integral component of the development agenda. This lack of interest in health matters was due predominantly to the framing of the role of the state in the development process in purely economic terms during the 1980s and ’90s. The World Bank set the mark for this vision with its structural adjustment programmes (SAPs). With SAPs it was expected that a low-income country would become effective through a process of adjustments to the financial and trade sectors of the country along neo-liberal lines. If the formula was adhered to, it was assumed that economic growth would take hold in a country and public services, such as a properly functioning health system, would automatically follow. As some had noted throughout these years, this understanding of the poverty cycle was too narrow.3 Development agencies focussed too much on the economic aspects of poverty alleviation, while leaving out many of the social factors that are attributable to poverty and not encouraging investment into basic services to the population. However, during this period, it was thought that these specialised agencies were producing the best ideas for development strategies, based on the data available and in-depth analysis. If health was not factored in, then it could not be perceived as a problem. Thus, as the spread of certain infectious diseases in the developing world was growing into a crisis, the development agencies could not sense the looming dangers and respond accordingly. Critical assessment among practitioners has now recognised that economic growth is not a single-solution road out of poverty but rather that health is a major determinant of economic growth and poverty alleviation. Macroeconomics and Health: Investing in Health for Economic Development, the report produced by the Commission on Macroeconomics and Health (2001), explicitly made this point and heralded the reversal of neo-liberal development policies focussed on economics. This appreciation, combined with the fact that in 1999 the world finally began waking up to the devastation of HIV/AIDS in Africa, meant that efforts to improve health in the developing world would need to make great leaps to catch up. Specialised responses above and beyond ODA would likely have been necessary to take on most of the growing health issues. But it was the failure to address HIV/AIDS in anything that approached a timely fashion that ensured the focus would be on infectious diseases. The first case of HIV/AIDS was diagnosed in 1981. But it was only in 1999 that the UN Security Council (UNSC) held an unprecedented special session on the matter and the World Bank established a department to work on the problem. Even the WHO was slow to put the issue on its radar screen throughout the 1980s (Mallaby 2004, 313–320). All international institutions and state-led development agencies failed to identify and act reasonably before the HIV/AIDS problem grew into what it is today. This incredibly slow response cemented the need to have a mechanism and strategy to fight infectious disease that moved beyond the parameters of development agencies and international institutions. Another consideration in the recent emergence of global health initiatives is the link between the security and development agendas over the past few years (UN 2005a, 5–6). This convergence has turned the matter of infectious disease into
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a development issue as well as a security question. With the anthrax scare after September 11, 2001, fears of the West Nile virus being used as a bioterrorism weapon, the sharp increase in death from HIV/AIDS in 1998, and the threat of an influenza pandemic, policy makers and experts took into account the problem of infectious disease and its impact on trade, economics, social stability, and concern for their citizens at home and interests abroad.4 With this conception of disease as a threat, even security agencies such as the U.S. Central Intelligence Agency (CIA) began to examine the needs of the developing world. Although infectious diseases can directly affect large populations, without the convergence of security and development at a time when the security paradigm is overwhelming a global response may not have been as prominent as it currently is. Linking the threat to other social and economic priorities has galvanised action and placed the issue high on the global agenda. A further factor that explains the recent popularity of global health initiative is the onset of the UN’s (2005b) Millennium Development Goals (MDGs), specifically MDG No. 6, which is to ‘combat HIV/AIDS, malaria and other diseases’. As the international community signed on to the Millennium Declaration in 2000, it propelled the challenge of eradicating infectious disease to the top of the development agenda. It also indicated that global strategies to address development issues were possible. Thus, global health initiatives became a natural extension of a host of other components. While this list of reasons for the rise in global health initiatives is not exhaustive, it indicates a build-up at the global level of the need to address infectious disease outside the established mechanisms. In essence, the rise in disease during the several decades that development agencies tended to omit health from their strategies, the convergence of the security and development agendas on disease, and the inclusion of infectious disease in the MDGs have pushed health onto the global agenda, and the response of initiatives specifically targeting disease reverberates loudest through the system of health governance. The Strengths of Global Health Initiatives There are several advantages to having a mechanism such as a global health initiative to address issues of infectious disease.5 These positive features contribute to the evolving governance system on health discussed below. Elevate the Issue Global health initiatives place infectious diseases front and centre at the global level. A well-formulated initiative will draw the attention of state, private sector, and civil society leaders to acknowledge the devastation caused by infectious disease and will compel them to act, while it also provides a route and vehicle for action. Once a global health initiative is established, it is not left to the whim of certain ministries or administrators to determine the extent of efforts to eradicate a disease. Rather, it solidifies a global consensus that the issue should be elevated to the top of the global agenda until major improvements are achieved. This has been particularly important in the case of HIV/AIDS. For years, the problem was not factored into development
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strategies or acknowledged in other policy discussions. A decade ago, the leaders of developing as well as developed countries could easily avoid a discussion on the issue (Mallaby 2004, 314). Now with the Global Fund, the ‘3 by 5’ initiative, IAVI, MDG No. 6, and other global health initiatives, there is a global consciousness that HIV/AIDS is a priority and that all actors play a role in eradicating it and mitigating its social and economic consequences.6 Leverage Resources To sustain the effort of eradicating a specific disease, global health initiatives have major resources at their disposal. The funds that back them ensure that the specific disease will not be forgotten. Acting as a central global account, such initiatives allow governments and other actors, including private foundations and donors, to contribute resources and leverage their impact by combining them with the resources of others. These contributions are monies that were either already engaged in the eradication of a disease or new funds that donors were persuaded to contribute. To date, the best-funded global health initiatives have been built on budgets in the billions of dollars. This is comparable to the amounts spent on health in the ODA budgets of industrialised countries, making the global response more effective than a single-state response to the problem. Inject New Resources and Create Incentives for Innovation Global health initiatives inject resources traditionally not available for disease eradication. Many of the strategic documents for these resources state that funds will be contributed where there have been gaps in funding. As such the money goes to new projects on the ground or new scientific research under the broad umbrella of the initiative’s strategy. There has been a notable—some say overwhelming—response to the call for projects carried out by global health initiatives, which demonstrates that traditional mechanisms have not been able to reach the potential that already exists.7 Thus with global health initiatives, new pots of money are put into the global system and as they are elevated above traditional mechanisms, new ideas and new solutions are able to come into being. Global health initiatives create a system of incentives to contribute to health challenges that was previously unavailable. Monitor Donors Global health initiatives create a system of donor monitoring that allows the tracking of the amounts committed and received for the particular cause. As the initiatives exist at the global level, most potential donors contribute to the same mechanism for each issue. Thus it is possible to keep track of donations and compare them. In additional, the existence of global health initiatives ensures that there is a mechanism in place to receive commitments that are made through statements, announcements, and media releases at summits and other international meetings.8 Some of these initiatives, such as the Global Fund, use replenishment conferences and well-developed donor relations programmes to ensure a commitment promised comes to fruition.
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Set Clear Targets Most global health initiatives set very precise targets with statistics and deadlines. This focus not only conveys the extent of the problem and a sense of urgency to eliminate the disease, but also signifies that there is a knowledge base for the amount and type of activities that should be pursued. Established targets indicate that there is a strong consensus on what needs to be done and how to do so. Not too long ago the governance question was what needed to be done. Now, as reflected by the existence of the global health initiatives themselves, it is increasingly a matter of getting it done. Commissions that have considered health and related issues such as social determinants and economic costs have given these answers; global health initiatives, by using goals, stimulate targeted action. Provide Coherence and Coordination By setting a global strategy, elevating the issue, leveraging resources, and maintaining a central point for the comparison of donor contributions and targets, global health initiatives make progress in the coherence and coordination of development strategies. For some time policy makers have grappled with the challenges of aid effectiveness, culminating in the UN’s International Conference on Financing for Development at Monterrey in 2002, where a major part of the discussions focussed on addressing systemic issues: ‘enhancing the coherence and consistency of the international monetary, financial and trading systems in support of development’ (UN 2002, 12). With traditional mechanisms, such as ODA, this approach can be quite difficult as styles of implementation and priorities vary from country to country. However, with global vehicles, as showcased by global health initiatives, the strategy is global and implementation streamlined, with great potential to limit duplication and the proliferation of donor meetings. The Problems Represented by Global Health Initiatives There are some core problems with the healthcare systems in developing countries, which are exacerbated by global health initiatives, despite their being a positive influence on the governance process for eradicating infectious disease. Simply put, many developing countries do not have anything near adequate resources. There are not enough practitioners in developing countries, nor are there enough facilities for their citizens. Without core health services, the well-being of a population is in jeopardy. Global health initiatives are not designed to address this central problem; they are meant to deliver vertical programmes to resolve emergencies that have appeared within a system that was not previously equipped to respond. The problems most exacerbated by this practice are internal brain drain, diminished capacity building, and short-term versus long-term vision. All need alternative programmes, most notably through ODA.
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Internal Brain Drain The global migration of health practitioners from low-income countries to the richer countries, often referred to as brain drain, is a major issue for developing countries. However, there is also the problem of internal brain drain, with health practitioners drawn to projects within the country that offer compensation significantly higher than the local standard. These positions are often with international agencies, and global health initiatives function in an advisory capacity for the implementation of a project. Thus health practitioners, typically the best left in the country, will migrate out of the public health system to participate in the vertical programmes addressing infectious disease, leaving the quality of the basic health services to deteriorate further. Of course, the global health projects and other vertical programmes must be properly staffed, but a continual drain on primary healthcare resources in developing countries left unaddressed is a serious concern. Short- and Medium-Term Goals Although global health initiatives can provide a sustained effort for resolving a particular problem, they are not a long-term solution to the healthcare needs of developing countries. Recent studies have looked at whether short-term vertical programmes can complement basic health services where health infrastructure is poor. Arguably, they do generate some lasting benefits; however, global health initiatives perceive and assess the healthcare services of a country in terms of the capacity to deliver the specific programme and not the overall strategies to address all public health concerns over an extended period (Forsberg 2001, 29). Reaching set targets for infectious disease rates are of fundamental interest to global health initiatives. This does not necessarily lead to the provision of services and activities to increase the overall health of the population. If this is the case, and these projects come in with significant resources, the wider healthcare systems may potentially be tilted and unbalanced toward the goals of the global health initiative and not the longer term needs of the country. The short- or medium-term modes of operation are understandable. But how the global health initiative integrates best with ensuring a longer-term whole-health sector strategy must be considered. Unbalanced Capacity Building The intention of global health initiatives is to bring together a global effort to resolve a global problem. However, most of the problem is in the global economic South and most of the driving force behind these initiatives is based in the global economic North. This imbalance means that the benefits and even the priority setting may at times fall closer to those administering the programmes rather than to the recipients. When vertical programmes are put into place in a country, external health experts and administrative staff are often brought in, instead of depending on local resources that may not have the required expertise—but could form a base of lasting capacity to address other health concerns (Forsberg 2001, 25). Furthermore, the types of solutions and projects deemed acceptable for the disbursement of a global health initiative’s funds may have a northern bias and
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may support capacity-building research and industry in the North (see, for example, Yale University 2005). The research may, of course, produce valuable advances in science, which can contribute to the eradication of disease; however, the focus is on pharmaceuticals and medical breakthroughs at the expense of projects in developing countries to address the social determinants of health or the development of expertise and capacity in these countries. Thus, although global health initiatives offer a global solution for eradicating disease, the imbalance between the North and South continues and must be considered in global health governance. Global health initiatives encourage an important system of vertical programmes as infectious diseases have become major obstacles to the well-being of many societies. Those diseases by necessity require targeted and large-scale responses. As a mechanism, global health initiatives have many positive features that work well to bring global actors together for an effective response. But they are not a catchall response to the health challenges facing the world today. Such initiatives are not intended to be comprehensive solutions. Rather, they are a component of a larger system of governance and provide a particular function. The shortfalls mentioned here, while global in scope, are not necessarily issues that the global health initiatives can address. They are multifaceted and require the action of many countries in partnership through other mechanisms, including a shift in ODA strategies in donor states. What Changes Are Being Made: Official Development Assistance This analysis of the global health initiatives must be complemented by an assessment of ODA strategies. ODA is the direct arm of income-rich countries that reaches into countries that require assistance. An examination of the health policies of the United Kingdom’s Department for International Development (DFID), the United States Agency for International Development (USAID), and the Canadian International Development Agency (CIDA) will provide insight into what horizontal or more general health issues are being addressed in developing countries. How do these ODA strategies take on the larger health problems that global health initiatives tend to address? Do those strategies acknowledge the existence of such structural problems for global health governance, and do they provide any insight? Have states taken on new responsibilities as needs and concerns evolve? Answers to these questions will reveal the level of responsiveness of the global health governance system. The three ODA strategies examined here, supplemented by the individual countries’ overall international policy statements, represent the vision of these states regarding development issues in the world today. Specifically, the health concerns outlined in these strategies are perceptions of what needs to be addressed in terms of health governance for the developing countries. Overall, these ODA strategies acknowledge many of the problems regarding infectious disease and the health concerns of nutrition, child mortality, and maternal health that are a part of the MDG framework. However, they do not delve deeply into matters of global health, such as brain drain, supporting primary and long-term health services, and capacity
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building for the South. In comparative terms, DFID’s (2000) white paper provides the most complete look at these broader problems and implementing corresponding programmes. Other ODA strategies lag behind. The United Kingdom’s Department for International Development In both the 2003 strategy of the UK’s Foreign and Commonwealth Office ([FCO] 2003, 14) and DFID’s (2000, 14) white paper, the links between development and security are strong. Accordingly, health challenges are considered a matter for global concern, predominantly seen through the lens of disease as a threat. The DFID (2000, 14) white paper acknowledges that effective vaccines against communicable diseases are a global public good, which ‘can and should be financed internationally’. The only mention of health in the FCO strategy is under priority number six (of eight), which is ‘sustainable development, underpinned by democracy, good governance and human rights’ and which lists the desire to ‘strengthen international action against AIDS, malaria and other epidemic diseases’ (FCO 2003, 14, 39). Again it is an infectious disease orientation. Thus the more recent FCO strategy does not give a full view of global health challenges. The more comprehensive discussions and valuable information for outlining the UK’s view of global health governance are found in the earlier DFID white paper. Throughout the DFID white paper, the sections dedicated to global health challenges consider the problems of brain drain and unbalanced capacity building in developing countries. In reflecting on the trend of global mobility, the white paper acknowledges that freedom of movement must be maintained; at the same time, it acknowledges that ‘these outflows can also be a drain on human resources in critically short supply’ and that research on this issue is necessary (DFID 2000, 43). In practice, the UK follows up on the brain drain issue with a National Health Service policy not to recruit health practitioners where doing so would have a negative impact on the health services of the home country (43). Additionally, DFID has begun to contribute large amounts of assistance funding earmarked to boost healthcare salaries in African countries to keep practitioners working where the shortages are extreme.9 In terms of capacity building, the DFID white paper outlines well the dilemma regarding research capacity: Most research and development capacity is in developed countries and is oriented to their needs. Research that benefits the poor is an example of a global public good which is underfunded. Not enough of the world’s knowledge is relevant for the needs of the poor. For instance, 90 per cent of the world’s disease burden is the subject of less than 10 percent of all international research on health (Global Forum for Health Research 1999; quoted in DFID 2000, 43).
DFID’s (2000, 44) white paper goes on to list some advances supported by the UK on this issue, such as IAVI and other global health initiatives, as well as attempts
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to encourage the production of needed, but low-profit, pharmaceuticals through price incentive schemes. On the discord between short-term assistance and the need to establish lasting comprehensive health services in the developing countries, the DFID white paper is lacking. It touches briefly on the need for effective healthcare systems in developing countries, but this is done in relation to the delivery of the programmes to eradicate disease (DFID 2000, 36). Here the paper does not allude to any greater quandaries such as the impact of short-term targets on core health services or the need to encourage sector-wide approaches while vertical responses are delivered through global health initiatives to meet the challenge of infectious diseases. United States Agency for International Development The U.S. State Department and USAID (2003) put out the first joint strategic plan in 2003, which covers the period from 2004 to 2009. This document marked a growing trend to place ‘international development in line with defense and diplomacy as the third pillar of U.S. national security’ (USAID 2005). It recognises that the primary health challenge is posed by infectious disease, particularly the HIV/AIDS crisis. It also declares that the U.S. government favours global responses such as global health initiatives, given that it is the foremost country donor to the Global Fund (U.S. Department of State and USAID 2003, 25; USAID 2002, 87). In fact, despite a tendency to push its own large-scale bilateral initiatives, such as the United States President’s Emergency Plan for AIDS Relief (PEPFAR), the U.S. government does pay attention to how its programmes fit in the overall global effort and framework (U.S. Department of State and USAID 2001). With regards to the issue of brain drain, both internal and more broadly, there is no discussion. The strategic plan refers briefly to the matter of migration but does not discuss its impact on health systems in the developing world (U.S. State Department and USAID 2003, 27). Additionally, the health section of USAID’s website mentions health systems, health workers, and health resources but not the international movement of health practitioners, despite the fact that the U.S. is a major recipient of such migrant workers, or the lack of resources in the developing world as a major cause of poor health services (USAID 2007). Rather, USAID focusses its strategies for improving health systems through cost effectiveness, implementation of best practices, and efficient time management. This can be a difficult set of solutions to implement when the health practitioners necessary are not available. The issue of local capacity for health matters as well as global research capacity is also not discussed. The USAID (2002, 85) document mentions that ‘for some diseases endemic in the developing world, particularly parasitic diseases, scientific knowledge remains inadequate to generate technological solutions in the near term’. It goes on to acknowledge that GAVI is working toward overcoming such problems. The lack of analysis of such growing concerns for health governance stems from the overall framing of health challenges in the developing world. USAID’s (2002)
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Foreign Aid in the National Interest largely sets out a view that future health issues will relate to the pursuit of a public versus private healthcare system, the treatment of chronic disease such as diabetes, cancer, and cardiovascular problems, and the rising costs of health care associated with these non-communicable diseases in developing countries. This analysis is more relevant to the situation in middle-income countries than in the poorest countries, and it is most interested in the opportunities arising from current trends in demography, urbanisation, and markets. The report recognises that there will be global growth in the health industry and encourages the decentralisation and privatisation of health systems in developing countries. While the concern over non-communicable diseases is a real one for the developing world (and recognised by the WHO), it is overemphasised in these documents meant to frame development issues, at the cost of dismissing the challenges facing the lowest-income countries. The result is a more market-oriented view of global health governance. The Canadian International Development Agency’s Statement In 2005, the Canadian government issued its far-reaching International Policy Statement (IPS), which included a substantial section on development (CIDA 2005b). Although this document was never officially adopted, it remains a reasonable indication of Canada’s official position on ODA in the context of health. The IPS emphasises meeting the challenge of HIV/AIDS, as do subsequent documents (CIDA 2007a, 2007b). Canada has taken this challenge seriously, as demonstrated by it being the ‘lead donor in providing $100 million to the WHO 3 by 5 Initiative’ (CIDA 2005b). CIDA’s (2001) earlier Social Development Priorities Strategy also indicates a dedication to the HIV/AIDS crisis as it sets out an action plan completely separate from the Action Plan for Health and Nutrition of the same strategy. In terms of addressing health challenges beyond the matter of infectious disease, neither the IPS nor the Sustainable Development Strategy discuss the problem of brain drain of health practitioners or the lack of research capacity for the South. CIDA (2005a) was noted for dedicating CA$5 million over five years to a WHO programme to address the shortage of workers. Although this effort was claimed to be generous, it is tiny compared to the existing need and the contributions of other agencies. Additionally, CIDA does not allow its project funds to be used for hospital infrastructure and operating costs or for the salaries of health practitioners.10 The earlier CIDA (2001, 35–37, 45) strategy considered the status of primary health care in the developing world and referred to both the shortage of health practitioners and inadequate research capacity. For CIDA, it appears that efforts to resolve these matters fall under the umbrella of strengthening health systems, which is ultimately left to the developing country government. In the 2001 strategy, CIDA places a strong emphasis on supporting governments to build their core health services and in ensuring their assistance programmes fit into a domestic sector-wide approach that suits the needs of the country (43, 54–56). This approach is taken because the sustainability and progress of primary health care require government leadership and commitment; donors in this case simply play a part.
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Indeed, the IPS states that ‘strengthening the capacity of health systems’ is a priority (CIDA 2005b). It includes ‘improvements in health training and staffing … and applied research’. The Sustainable Development Strategy states that ‘CIDA will continue to collaborate with key Canadian, international, and developing-country partners in an effort to build country capacity’, which includes ‘policies, initiatives, and relevant research’ that, among other things, ‘strengthen health systems’ (CIDA 2005b). However, in lumping together the growing problems regarding brain drain, research capacity, and integrating the short-term goals of global health initiatives with long-term needs, the complexity of such issues is lost. By assuming that these issues are still a part of the domestic discussion about health systems, where CIDA supports governments rather than initiates responses, the global aspect of the problems is not fully recognised. These challenges are thus considered something the developing country can manage on its own.
The Overall Assessment of ODA in Global Health Governance This chapter began by analysing global health initiatives as tools for eradicating disease with significant resources and positive attributes. It also showed that these initiatives can disturb and distort some of the other global health challenges, notably brain drain, capacity building in research and local expertise for health, and maintenance of a long-term core health service in developing countries. If there is to be a comprehensive and proactive global health governance system, these issues must be discussed in policy and must extend to other governance tools, such as ODA. If not taken up by development agencies, these challenges will likely remain untouched by the global health governance system. With regard to the ODA policies of three major donor countries, there are some declarations but not much substantive discussion on these problems, which leaves an incomplete picture of global health governance. The three ODA strategies outline an understanding of the concept of health as a global issue that fits with development issues. They acknowledged the need for a global response to the problem of infectious disease, especially HIV/AIDS. They all support the connection between development and security. Thus epidemics are identified as the prominent health issue or, rather, as a security threat. They recognise health as a determinant of economic growth, and both DFID and CIDA see the MDGs as the foremost global development strategy. DFID (2000, 12) even acknowledges that the development strategies of the 1980s and ’90s focussed too much on economics and were subordinated to commercial interests. In terms of a governance system for development and global health, the ODA strategies support multilateral cooperation and contribute to global efforts such as global health initiatives. However, they tend to avoid marking out a specific role, or new set of tasks, for their agencies that would complement these mechanisms in response to global challenges. Despite the agencies’ years of experience in delivering ODA, there is no forward-looking vision of what can be done to improve current health conditions on a global level and of how to address future changes.
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If global health initiatives are to be successful in eradicating disease, support from development agencies is important. But so, too, is action on the other issues that pose problems for health delivery in resource-poor countries. The development agencies fail to look beyond the work being done on infectious diseases and other global initiatives. Because of insufficient discussion and because those other health challenges are not identified, the development agencies are not prepared to address these issues appropriately in their ODA programmes. An additional sore point is that the ODA policies on global health were slow to recognise the HIV/AIDS crisis. The response has definitely improved, but there is no explanation of why it took close to two decades for real action on this problem. Discussions of early warning systems, new concepts for global health, action on behalf of the most vulnerable, and the use of statistics to indicate emergencies would be useful in the ODA strategies to improve the response to health challenges. Overall, however, the ODA policies show movement on the global health front in the development strategies of the UK, the U.S., and Canada. Such movement is geared mostly to the challenge of infectious diseases and is supported by a consensus on the need for concerted global action. But the ODA policies do not demonstrate a strong recognition of the other global health challenges that are upcoming and amplified by global health initiatives. There is little thinking on how to complement the newest mechanisms that address health concerns or on planning to prevent future crises, including an examination of what was missed in the case of HIV/AIDS developing into the state of emergency it is today. ODA remains more reactionary in the context of global health than being a proactive plan for a comprehensive global health governance system that it would work alongside global health intiatives.
The Current Global Health Governance Process Through this assessment of global health governance mechanisms, global health initiatives emerge as an important and innovative response to a longstanding problem, while ODA is not setting the pace in addressing other health challenges. What does this say about the global health governance process and agenda? How can the system be improved? Several themes emerge in response. The first theme is convergence. The increase of global health initiatives in the current context is largely due to the convergence of the security and development agendas, which has pushed the threat of infectious diseases and potential pandemics to the top of the global agenda. Such linking ensures that issues get support from those that have the resources to deliver. In terms of eliciting action, the U.S. has been interested in addressing matters that are couched in a security framework. Indeed, this focus has become exaggerated so that the response to infectious diseases is no longer seen as a global public good but rather as a way to prevent bioterrorism and provide security. This form of linkage can therefore be counterproductive as it distorts the larger health governance agenda.
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Convergence is also reflected at the North–South level. The Global Fund (2008) came into existence only once the G8 countries and the African leaders had endorsed such an initiative at the 2001 Genoa Summit. As UN secretary general Kofi Annan encouraged these constituencies over a series of encounters to finalise plans for the initiative. It was necessary to have an international level organisation or figure carry the idea of a global initiative for some time so that the different states could come to a collaborative response. Indeed, the form of collaboration that has occurred is a second theme. In the case of global health initiatives, states participate in a global campaign or network-like structure alongside other actors. Anne-Marie Slaughter (2005, 284) explains the idea of government ‘networks’, which parallel other global networks of actors, which she identifies as terrorists and international criminal activity. For Slaughter, networks create a ‘world of governments, with all the different institutions that perform the basic functions of governments … interacting both with each other domestically and also with their foreign and supranational counterparts. States still exist in this world; indeed, they are crucial actors. But they are “disaggregated”’ and the ‘result could be a world crisscrossed by an increasingly dense web of networks.’ Although Slaughter focusses on networks of government officials in the traditional legislative sense, the concept very much applies to health issues and the collaboration found within the mechanism of a global health initiative among state officials and representatives of international institutions, private foundations, research centres, the private sector, and nongovernmental organisations (NGOs). Networks in the broad sense and global health initiatives more specifically bring together all the international institutions and other global actors that should be involved in resolving a problem without forming a rigid, heavy global structure. This can be seen with global health initiatives as they work alongside the World Bank, the WHO, UNAIDS, and country teams on a specific disease. This network structure is a mechanism that harnesses the potential gains from cooperation that globalisation permits (Keohane 2001; cited in Slaughter 2005, 292). The expansion of global health initiatives has been an excellent response to a global problem of increased infectious disease, although it was much delayed. The use of convergence and the network format have been important for this response to be effective. However, this indicates that problems in the current global health governance system may have to reach the level of security threat for serious global action to be taken. The concept of planning and prevention on global health issues has not been implanted into global governance. States are not yet formulating the greater health challenges through their ODA strategies so that those challenges can be pushed onto the global agenda. Thus, the chance of them being addressed before they reach crisis level is significantly lowered. If the current global health governance system is more prone to responding to emergencies than planning to prevent them, what improvements could be made? The principle of convergence as effective traction and the principle of global networks as a useful mode of cooperation can be useful in devising potential solutions.
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Possible Next Steps to Avoid Emergency Room Syndrome One possibility is to strengthen the international organisations that would carry a health issue long enough that actors mutually recognise it as problem and are willing to collaborate. This was part of the process in establishing the Global Fund, as well as other global initiatives. The principal organisation for such a role in meeting global health challenges has remained the WHO. Although within the UN system, the WHO may not have all the capacities and strengths necessary to push global health challenges to the top of the governance agenda. Thus, it is important to consider how to position the WHO on the cusp of the issues that make the global agenda. It needs to be more integrated into policy areas that are consistently on the minds of leaders so it could thus produce more compelling arguments for its member states to act and innovate to meet health challenges. This is currently not the case; even the document produced at the 2005 UN World Summit failed to pursue any major health issues (UN 2005a). Yet the UN is the umbrella for the WHO and is consistently involved in the security and development agendas. Thus the WHO needs to be brought into the more mainstream discussions of policy and decision making. Another area is the management of the global system through clubs or networks. The most prominent club is the G8. Yet the agendas it sets and the actions it takes do not fully recognise the needs of the developing world. If this club were expanded to a network to include countries from each region of the world (such as the leaders G20 have done in the realm of finance and economics) to involve the emerging economies, especially those often invited to G8 meetings, the agenda-setting process would be more comprehensive. Bringing in a new network of countries may open up discussion on some of the challenges mentioned in this chapter. For example, the issue of brain drain could be reframed as a migration and labour issue. A discussion on capacity building and research and development could lead to spreading resources across the network. Certainly, India and China have issues with population health and migration. They are also potential players in the world of product development and innovation. If too little attention is paid to these emerging powers, the governance system will fail to recognise growing challenges as well as innovative solutions. Finally, one area that should be developed to encourage more comprehensive global health governance is the concept of global public goods. Some of the ODA strategies referred to health as a global public good, but it is unclear what type of action such a concept demands. A consistent understanding of global public goods and the continued development of the term would assist in getting global collaboration on health challenges and would ensure those challenges are dealt with on the global agenda in a preventive manner, and not as an emergency response.
Notes 1 On health as a global public good, see Richard Smith, Robert Beaglehole, David Woodward, et al. (2005) and Inge Kaul, Katell Le Gaulvain, and Mirjam Schnupf (2002).
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2 Vertical programmes are defined as ‘centrally managed, disease-specific initiatives that are isolated from broader health services’ (Center for Global Development 2008a, point 7). 3 For a discussion of World Bank policies during the 1980s and ’90s, see Thomas Biersteker (1995), Adrian Leftwich (1993), Lloyd Pettiford and Melissa Curley (1996, 21–37), Anthony Payne (1999, 373), and Bonnie Campbell (2000). 4 For example, see the National Intelligence Council (2000). 5 For a description of successful global health initiatives see the Center for Global Development’s (2008b) Millions Saved Project. 6 Even if actors do not participate, global health initiative have a sensitising effect that provides a framework for contributions toward the disease. For example, the 2003 United States President’s Emergency Plan for AIDS Relief (PEPFAR) has contributed a large amount of money and activity to meeting the challenge of HIV/AIDS. It is no surprise that the Bush administration, as an actor that did not traditionally work through multilateral initiatives, chose to create a purely American initiative; however, the decision to establish a programme for HIV/AIDS is likely related to the various existing global health initiatives, specifically the Global Fund, and to the pressure to act on the issue. 7 See the comment by Nobel laureate Dr. Harold Varmus in the press release published by Grand Challenges in Global Health (2005). A global health initiative can also ensure that more funds are spent. The development agencies of some donor countries have difficulties spending their entire budget in a year; thus the initiative provides an outlet for absorbing funds for projects that fit goals of the agencies. 9 See, for example, DFID (2004) and Stephanie Nolen (2005). 10 Personal correspondence with the CIDA information service.
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Part VII Conclusion
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Chapter 16
Innovation in Global Health Governance John J. Kirton and Andrew F. Cooper
The chapters in this volume explore a wide range of physical challenges, public responses, and governance innovation regarding the major diseases that largely define the field of global health today. Amidst this rich detail and diversity, several patterns stand out. They largely affirm the central argument of this volume that in today’s world where the new vulnerability dominates, the old formulas of Westphalian governance have failed and a new generation of innovation from many actors is emerging to take its place. But while the new vulnerability provides an increasingly powerful driver, a new world of institutionalised innovativeness and multi-centred sovereignty has yet to replace the Westphalian order of old. As a result people still die unnecessarily in large numbers all over the planet, as the struggle to produce global health governance appropriate for the 21st century goes on. This chapter charts the main patterns that sustain these conclusions, following the analytical framework outlined in the introduction (see Appendix 16-1); these conclusions have been developed and tested on the basis of the case studies presented in this book. The chapter looks first at the challenge brought by globalised health threats in today’s 21st-century world. It then examines the responses of the wide array of public actors now involved in global health. It next explores the innovations produced by these responses to the new challenges. It concludes by assessing the responsiveness, appropriateness, and effectiveness of the current system of global health governance and its movement toward a post-Westphalian form.
Challenge: The New Globalised Threat There is overwhelming consensus among the contributors to this volume that the physical challenges to global health are great and growing as the globalising world of the 21st century unfolds. To be sure, there is considerable progress on some fronts, and new data and measurement methods suggest some hope in the long war against HIV/AIDS. But with the possible exception of severe acute respiratory syndrome (SARS), there has yet to be another success such as smallpox, with a major killer successfully banished for good. And after a quarter century of the campaign against HIV/AIDS, it remains without the preventive vaccines that those fighting polio and even avian influenza possess.
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Disease As Andrew Price-Smith and Yanzhong Huang note, public health victories peaked in the mid 1970s. The world has been on the defensive ever since against the assaults from HIV/AIDS, bovine spongiform encephalopathy (BSE), West Nile virus, SARS, and virulent H5N1 avian influenza. Caroline Khoubessarian confirms that there has been a spike in new infectious diseases, with more than 30 unknown diseases related to bacteria and viruses emerging since 1973. Appendix 16-2 charts the most salient cases in this deadly cadence. It shows that diseases are erupting faster, more fully, and farther around the globe. Communicable disease is no longer a problem banished from a well-protected global economic North, but one that has erupted in, and flowed between, both the rich North and poor South alike. Pathogens rapidly evolve and colonise ecological niches, even in the most developed states. Thus the world is still battling the big five challenges of HIV/AIDS, tobacco, avian influenza, and polio, and even a recently defeated SARS can easily re-emerge from its animal reservoir. Even with SARS, the least prevalent case thus far, there is little cause for celebration or complacency. SARS was a classic outbreak event. In the ten months following 1 November 2002, 8096 humans were infected, ranging from 5327 in China where it started, 1755 in neighbouring Hong Kong, 346 in nearby Taiwan, to 251 in distant Canada and 27 in the much larger United States. SARS had high virulence, transmissibility, and a rapid incubation period, along with an initially unknown cause, transmission mode, and treatment. It infected not only neighbours and fellow travellers but also a large number of medical personnel. It erupted in the form of multiple, virtually simultaneous outbreaks around the world. Avian influenza has thus far also been well contained. But complacency and confidence are challenged by the growing consensus that it is an outbreak event about to arrive in full force. The large number of birds and animals at its source and the great growth in novel sub-types of avian influenza in humans make many feel the world is on the verge of another influenza pandemic, comparable to those in 1968, 1957, and 1918. The frequency of such outbreaks is increasing. The next will probably be highly virulent, transmissible, and deadly, like that in 1918. The H5N1 variant, appearing in Thailand and Vietnam in January 2002, mutates rapidly, acquires genes from viruses infecting other animal species, and has high virulence. But the precise timing, source, and pathway of the next influenza pandemic are unpredictable. And like the 1976 swine influenza in the U.S., there is some chance it may never come. HIV/AIDS is an attrition disease that the world has been battling for more than a quarter of a century now. An estimated 33.2 million people live with the virus, for which there is still no cure. From its epicentre in southern Africa, where it affects 20 percent of those aged 15 to 49, its prevalence is rising in many countries. It features a long incubation period, a high certainty of morbidity, and a few pathways that are well known and capable of being controlled. Polio, another attrition case, is the most promising, for the number of those infected has dropped dramatically over the past 25 years. But its persistence in
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the face of a major campaign to eradicate it shows how difficult it is to produce a success such as smallpox in today’s world. In 2006, a year after the target year for polio’s eradication from the planet, 676 new cases sprung up in India (Global Polio Eradication Initiative 2008). Nigeria had more than 1122 cases in the same year. Tobacco-related diseases constitute an attrition case that has been spreading, as more people on the planet smoke and contract the predictable conditions that smoking brings. The causes, pathways, and predictable results are known with a high degree of certainty, as are the measures for the control of tobacco. It is fully under the control of the individuals it harms and who harm others with second-hand smoke. But despite high degrees of scientific certainty and human control, the global tobacco pandemic grows. Each of these cases poses a major challenge. Some have and could overwhelm the capacity of even the most capable state to control. But taken together along with the many other new diseases, there is great uncertainty about which will erupt as the greatest threat and thus demand the most resources in response. Moreover, the world now faces the ominous possibility of having to combat two pandemics at once. Source The novelty of the 21st-century health challenge starts at the source of these diseases. The chapters in this volume confirm that there has been a shift disease. Long gone are the Cold War decades in which the world’s major powers developed, deployed, and prepared to use or defend themselves against bioweapons. In their place has arisen the use of bioweapons by non-state human actors, such as the anthrax attacks in America in the autumn of 2001. As Price-Smith and Huang indicate, the end of the Cold War closed the era when powerful states deliberately developed and deployed biological weapons for use against the opposing military or civilian populations of state adversaries in the inter-state competitions and wars of old. But the post–Cold War period brought bioterrorism, with human actors using disease for apparently political purposes too. Human are also the source of the diseases they inflict on themselves, their partners, and their neighbours, as the cases of HIV/AIDS and smoking suggest. But threats arising from animals and birds and passing into humans are also a compelling threat. Carolyn Bennett notes that an estimated 80 percent of new and emerging diseases originate in these non-human sources. The SARS coronavirus is a new zoonotic pathogen that moved from its animal reservoir in civet cats in China into humans. Influenza also started in birds or swine or a different animal and crossed to humans, with the next stage of human-tohuman transmission threatening to come soon. The 1918 influenza pandemic came completely from avian sources. Those sources act as a reservoir that give today’s avian influenza enormous staying power, making eradication difficult, despite the short-lived success in Hong Kong when it appeared in chickens there. H5N1 is now endemic in southeast Asia. Avian influenza is more contagious and virulent than SARS and can be spread by asymptomatic carriers. And, in all cases, pathogens mutate and beat the immunisation deployed as a human defence.
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Process The multiple sources and reservoirs and biological mutations make the new diseases more difficult to control. The new health threats lack the intentionality, targeting, and guidance of the bioweapons of old. To be sure, smoking is controllable by the many millions who engage in it, but the addictive properties of cigarettes and the influence of the tobacco industry make it more difficult to stop. HIV/AIDS transmission is similarly controllable by the many million carriers, but their sexual activity and drug addictions make the proven defences of abstinence, faithfulness, and condoms difficult to deploy. At the other end of the spectrum, human carriers or victims could not readily control the SARS coronavirus, which spread through infectious respiratory droplets by direct contact through eyes, nose, and mouth. Pathway The spread of these diseases similarly shows the emergence of a globalised microbial world. A quarter of a century ago diseases once prevalent in the global economic North, such as polio, malaria, and tuberculosis, had been conquered there. They also promised to be eliminated in the South, as smallpox had been in 1979. The North was thus largely left to deal with its self-inflicted diseases of affluence, such as tobacco, obesity, cancer, and heart disease. And there was hope that vaccines, like those discovered in the U.S. in 1961 to eliminate polio, could be deployed and discovered in the South as well. But HIV/AIDS, although discovered in the North in 1981, has spread throughout the South where it originated largely unchecked, with 60 percent of the world’s infected population living in southern Africa alone. Tobacco use is being contained in the North but is similarly spreading throughout the South. At the same time, there has arisen a reverse flow from South to North. That SARS started in China and flowed into North America destroyed the assumption that communicable disease had largely become a problem only for the underdeveloped South. And avian influenza is now also spreading relentlessly from South to North. Most important has been the advent of simultaneity on a fully global scale. Disease once spread slowly to a few neighbouring countries in a step-by-step linear advance. But SARS erupted almost at the same time in countries as far apart as China and Canada. Avian influenza could spread in similar fashion as well. Airline routes and bird flyways can immediately take a disease from almost anywhere to almost anywhere. As Adam Kamradt-Scott notes, in the case of SARS never before had so many countries been afflicted at same time. The physical health challenge has now become a simultaneous global one. Causes There are many causes of these new cadences, with many being featured on several authors’ lists. At the core lies the biology of microbial mutation and transfer. In
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the ecological realm, environmental pollution, climate change, and bird flyways encourage and spread disease. In the social realm, the population explosion, aging populations with weakened immune systems, and dense urbanisation foster the spread. In the economic realm, unequal resource distributions produce vulnerable areas for outbreak, while the greater speed, scope, and scale of international trade and tourism transfer diseases rapidly around the world. In the political realm, conflicts of both interstate and intrastate types and suspicions of former imperial powers makes it hard to reach people with vaccines and medicines, as shown by the persistence of polio in Nigeria and HIV/AIDS in South Africa. Standing out as the great causal multipliers are the social-psychological factors of fatalism, fear, stigma, and solidarity. Fatalism and fear are by no means new human reactions to mounting disease, as Thucydides’ account of the plague in Athens shows. But their dynamics can now spread much further and faster with a much magnified effect. Fatalism itself seems to have withered, as the advance of modern medicine and the profession of public health have led most to assume that they can be protected from or cured of disease. But stigma is still potent. As Huang points out, Jews were considered scapegoats as spreaders of the Black Death in Europe and killed en masse as a result. More recently, a quarter of the population fled the infected Indian city of Surat in four days, leading those around the world to fear the disease would thus be brought to them. Hany Besada shows that stigma still fosters the spread of HIV/AIDS in southern Africa. SARS led to the shunning of Asian travellers, restaurants, visible minorities, and the entire expanse of the second largest country in the world, in which only one city experienced infections. It was such shunning that did the real economic damage and had social costs long after the physical challenge had been met. Yet as Huang recalls, the 1918 influenza pandemic also led to social solidarity of the sort often seen within countries that are at war, especially when victory is felt to be close at hand. To be sure, different clusters of causes arise in different diseases and countries. These causal cocktails make it important to determine the relevant salience of a wide array of causes across these different domains and place priority on the most potent ones. But, above all, the challenge is a comprehensive, interconnected one that embraces all spheres of collective human life. Such a physical challenge cries out for a similarly holistic public response.
Response In the cases examined in this volume, such a response has seldom arisen across the full repertoire of collective action taken by actors, beyond the family or clan, to treat or prevent the physical challenges of illness. Rather, the response has usually involved only a few of the relevant actors, using in cybernetic fashion their existing repertoires of instruments, standard operating procedures and knowledge, acting at the borders or within their own countries, and doing so in a closed, partial, uncoordinated way.
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Actors Each of the five cases shows the broad range of actors now involved in the field of global health. These range from individual activists, professionals, private firms, nongovernmental organisations (NGOs), states with their national and sub-national governments and international institutions, with ever more types of actors entering the global health game. Yet partly as a result of this expansion, rarely are these actors all active at the start or at the end. Moreover, the resulting configuration still shows considerable inequality in capability, skill, and the influence that results. At the centre of this configuration stands the sovereign nation-state, acting in the self-interested way in a self-help world that realist theory in international relations predicts. As Kathryn White and Maria Banda emphasise, these states have the primary authority, accountability, and responsibility for regulation, education, and enforcement. Yet within the central governments of consequential countries, more departments are becoming involved, including the powerful departments for agriculture, finance, development, trade, foreign policy, national security, and national intelligence, as well as the traditionally low-ranking and isolated ones responsible for environment and for health. National leaders too are becoming active as health rises on the public policy agenda. sNonetheless, within large countries with federal systems, sub-national and local governments play a critical role. Provinces, cities, and local hospitals were the first responders when Canada and China confronted the SARS crisis. And even when the national government acts first, as in small compact polities such as Singapore and Hong Kong, the decisions of local hospitals matter a great deal. Within and across national borders, private firms, foundations, and NGOs play an important part. As shown by Jillian Cohen-Kohler, Jeff Collin, and Kelley Lee, mega mergers have created powerful global firms that act on many fronts to secure their preferred outcomes for access to affordable HIV/AIDS medicines and tobacco control. Yet they are now countered by a growing and more global set of NGOs such as Médecins Sans Frontières (MSF), reinforced by the major development and environmental civil society organisations now becoming active on the global health front. Private philanthropy and foundations also matter, from the Rockefeller Foundation of old to today’s Rotary International, with the latter being one of the few NGOs to make financial contributions to the United Nations system and to deploy more than a million volunteers world-wide in the polio eradication cause. Also active at the societal level are the media, which revealed the presence of avian influenza in Hong Kong in 1997. The internet, which facilitates wide-scale communication, is becoming a key, fully global actor for engaging in surveillance, sharing information, and directly shaping individual citizens’ responses to disease. International organisations and institutions are increasingly involved and influential. Appendix 16-3 shows the leading actors in the large array of such bodies now contributing to global health governance. Some have acquired the regulatory authority once possessed by national governments, as the European Union has for high-risk meats. The case of tobacco shows how individuals within international
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organisations such as the World Health Organization (WHO) can play a critical role, both at the very top, in the person of Gro Harlem Brundtland exercising leadership, and at lower levels from committed individuals equipped with both scientific expertise and policy skills. As Kamradt-Scott shows, the case of SARS shows these levels coming together to produce a most forceful WHO response. Actions Yet in most instances these many new actors still behave in old ways, with their built-in repertoire of instruments, standard operating procedures, and inherited knowledge. They behave in semi-conscious fashion as cybernetic actors responding to a few stimuli, rather than as analytically rational decision makers comprehensively assessing all inputs and alternatives to choose the optimum one (Steinbruner 2002). They thus respond with routines that can make the challenge even worse. Across the five cases, the tendency is for sovereign governments to assume and assert control and to deny or suppress knowledge of the problem while they treat it in traditional ways. In the case of SARS, this was through standard medical techniques. With HIV/AIDS in South Africa, it was on the basis of unproven theories that disputed the links between HIV and AIDS and that privileged traditional local foods such as beetroot rather than antiretroviral therapy (ART). The resurgence of polio in Nigeria was also fuelled by local governments responding to vaccines as the malevolent instruments of outside imperial powers. And the rules for the Canadian International Development Agency (CIDA) prevent Canada’s official development assistance (ODA) from financing physical infrastructure or salaries in recipient states. Compounding this tendency is the instinct of multilateral organisations to defer to the sovereign prerogatives of their member states. Thus Kamradt-Scott shows that at the start of the SARS case the WHO acted according to its constitution, which empowers it to ‘perform duties assigned to the Organization’ by its members. Similarly Bennett notes that the World Bank, using its standard method, declared that Brazil lacked the capacity to deal effectively with HIV/AIDS. At the same time, the routines of other actors make for a contested field. Private firms overwhelmingly invent and produce new medicines for the lucrative market in rich countries, rather than the medicines for neglected diseases primarily of interest to the poor. The internet meant that news about SARS leaked into China. As Sonny Shiu-Hing Lo shows, mass publics demanded actions that were not always optimal, such as temperature-testing equipment at airports in the case of SARS and refusing to demand pandemic preparedness plans once the SARS crisis has passed. This reliance on old routines is often grounded in an attachment to existing knowledge and ideas. The success in eradicating smallpox still serves as a model for combating other infectious diseases. The almost millennium-old technique of quarantine remains a core part of the repertoire in a now much more globalised age. The three health goals of the Millennium Development Goals (MDGs) reflect in part a theory of how health could best contribute to development, and have thus relegated to second place key health objects such as access to affordable medicines for HIV/
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AIDS in their own right. And neo-liberal paradigms privileging economic theories and value have long guided the response to medicines for HIV/AIDS and tobacco control, as emphasised by Cohen-Kohler and by Collin and Lee. Targets The centrality of state actors and their repertoires means that most responses are still largely targeted at the borders of the territory that these sovereigns fully control, or within that territory itself. These states are asked to conduct surveillance and voluntarily provide information to those abroad. The instruments of quarantine and isolation were deployed against SARS, with the latter producing stigma as a side effect. Hong Kong used coercive regulation, slaughtering all its poultry within three days with little regard for animal rights. Efforts to generate national stockpiles of drugs for a strategic medicine reserve to protect a domestic population is a dominant response to avian influenza, even if the drugs can be rendered ineffective against the challenge of a rapidly mutating disease. And even Rotary International, with its global network of volunteers, was impeded in its effort to eradicate polio by the actions of the Nigerian state. Defence at the border is also a preferred target as threatened states instinctively move to construct a medical Maginot Line. Several states installed temperature sensors at airports to detect SARS. Outside actors similarly seek to seal off the borders of an infected state. Huang notes the fear that countries will hoard their national stockpiles of influenza vaccines through export bans when the pandemic strikes. Such a fear has already led Indonesia to threaten to hoard its own national avian influenza samples until it receives assurances that those that hold the resulting vaccines abroad will share the medicines and technology. As Price-Smith and Huang indicate, SARS gave rise to calls to suspend all travel links with China, and 100 of its 164 diplomatic partners actually did to some degree. The WHO imposed a travel advisory on Toronto. Its International Health Regulations (IHR) also target borders as a key line of defence. Defence in depth in the distant locations where the challenges first arise remains all too rare a response. The instrument of ODA, confined by state sovereignty, tends to be funnelled indirectly through intergovernmental organisations and national governments, with the many stages and opportunities for slippage that such a circuitous route entails. Its use for local infrastructure or salaries can be prohibited. Despite measures such as the training of Vietnamese technicians in laboratories in Canada, as described by Bennett, there is little desire to build capacity in the developing world, where a lack of basic healthcare systems and services allows pathogens to spread easily. Processes Perhaps most importantly, the process of response seldom shows high degrees of comprehensiveness, communication, cooperation, coordination, coherence, compliance, and capacity.
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Comprehensiveness was often compromised. Relevant actors and actions were excluded from the alternatives assessed and responses chosen. Bennett notes that Canada confronted SARS without a ‘whole-of-government approach’. Health ministries went alone to the WHO without their statistics agencies and other relevant departments at their side. However, Benedikte Dal, Laura Sunderland, and Nick Drager note that this is starting to change as the WHO’s work on health diplomacy gets underway. Communication is often replaced by closure, cover-up, and criticism. Both Hong Kong, facing avian influenza in 1997, and China, confronting SARS in 2002, at first refused to report they had a problem and later moved from denial to lie. Canada too disputed the WHO travel advisory against Toronto, even though within the country information was not shared among those involved and the lines of communication among actors and with the public was very poor. Cooperation, too, is often lacking. Canada confronted SARS without federal– provincial cooperation and a collaborative framework and ethos, as Bennett shows. And Huang’s ideal of a strong state working with civil society remains rare. Coordination and coherence are fragile and sporadic. Tobacco became a global pandemic in part because health ministries remain weak and isolated within their own governments. The SARS outbreak saw a lack of leadership at the highest level in China and Canada, tensions among relevant departments, and even negotiations among agencies in China for access to samples. And by November 2006, only 60 percent of countries had a national strategy for pandemic preparedness of any kind. Huang judges that harmonised, holistic strategies remain rare. More broadly, Khoubessarian emphasises the lack of integration of health with international policy in the U.S., Britain, and Canada. Compliance is often weak at all levels. In the SARS case, at the local level, the refusal of one healthcare worker to comply with a voluntary quarantine led to the infection of dozens in a Toronto religious community. The World Bank and the WHO rely on states voluntarily to survey, report, and enforce quarantines. And as John Kirton, Nikolai Roudev, Laura Sunderland, and Catherine Kunz show, compliance with the G8’s growing health commitments is the weakest across the six functions G8 governance performs. Capacity is probably the greatest gap. White and Banda as well as Bennett note that the neo-liberal ethos of privatisation, deregulation, and decentralisation have weakened state capacity on animal health. Healthcare systems, infrastructure, and personnel remain poor in the developing world. And Huang notes that even the rich North faces the next avian influenza pandemic with technology from the 1950s, limited production capacity, and an existing system that may be weakened once the pandemic hits. More important is the lack of surplus capacity and adaptive resilience in the overall healthcare system (Dewitt and Kirton 1983). Price-Smith and Huang highlight the lack of surge capacity in the face of SARS and avian influenza, as governments seek to operate their healthcare systems in the most efficient and affordable way. Only in the WHO’s response to SARS were there clear signs of the agency slack
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that allowed the body to use its residual and emerging constitutional authority and credibility to attack the disease directly at its source.
Innovation The shortcomings in response have been accompanied by a cornucopia of innovations and have inspired even more, coming with growing frequency and force. These innovations extend from revisions of individual instruments in the existing repertoire, through novel additions, to far-reaching changes across the system as a whole (see Appendix 16-4). Actors Across all five cases, innovation has come from virtually all of the many actors involved in global health governance. Individuals alone act as empowered epistemic and policy entrepreneurs (Rosenau 1990). As Collin and Lee show in the case of tobacco, academic lawyers such as Allyn Taylor and advocates such as Ruth Roemer can ultimately have a decisive global effect. Individuals are also important through the foundations they endow and the many global health initiatives they mount. Where the Rockefeller Foundation once stood as a somewhat lonely if decisively important actor, now Bill Clinton, Bill and Melinda Gates, and others are influential on HIV/AIDS and many other fronts. They have been joined by individual celebrities from many professions who lend their name and fame to the cause of mobilising attention and resources to combat the challenge of communicable and non-communicable disease (Cooper 2007). Private sector firms and associations are important innovators, if at times reluctant ones. As Cohen-Kohler and Lisa Forman describe, pharmaceutical firms that have now gone global are central in developing and providing affordable access to the medicines needed for HIV/AIDS. As Collin and Lee detail, the private sector was similarly central in the case of tobacco. More broadly, it has a lead role in the creation of voluntary standards and programmes for corporate social responsibility. Yet as they have gone global, they have encountered an increasing number of other actors, with the result that innovation is inhibited, increased, or directed in new ways. Moreover, as Collin and Lee indicate in the case of tobacco, even the great global firms within an industry have differing corporate strategies and philosophies, and are at times divided, in ways that allow innovation to surge through. Yet in the end they remain driven by the demands of the market, as the virtual absence of research and development (R&D) on drugs for tropical diseases suggests. Civil society is another actor. It is central in the case of polio and important to the outcomes on HIV/AIDS. It assumes many forms, from global service organisations such as Rotary International to local community associations that can decisively combat disease, as the fight against avian influenza in Asia shows. Rotary has raised more than US$135 million since 2002 for polio, indicating how powerful civil
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society can become in mobilising money. Local networks and faith groups innovated in the campaign against AIDS in southern Africa, as Besada notes. Civil society also drove change in the negotiation of the Framework Convention on Tobacco Control (FCTC). Increasingly civil society organisations are going global and becoming central actors in the proliferating array of global health initiatives focussed on a single disease (Orbinski 2007). Media coverage also makes a difference. In the case of SARS, as Lo traces, the media uncovered the Chinese government’s initial cover-up, and then that government used the media to get the message out. Forman shows how American civil society used the media during a presidential election campaign to change U.S. policy on access to affordable medicine for HIV/AIDS. National governments too are important sources of innovation, in both the developed and the developing worlds. Yet in a paradox for standard realist theory, it is often the most capable governments that innovate the least. Thus the U.S. government led the resistance against access to affordable medicines for HIV/AIDS, and threatened and used trade sanctions, as Cohen-Kohler and Forman relate. The United States, Japan, and Germany were similarly opposed to the convention on tobacco, as Collin and Lee show. Nonetheless Japan forged the link between health and gender and took the initiative at the G8 summit it hosted in Okinawa in 2000, which produced the Global Fund to Fight AIDS, Tuberculosis, and Malaria at the G8 hosted by Italy in Genoa in 2001. Less capable countries such as Canada have been important innovators, as in the aftermath of SARS in anticipation of an avian influenza pandemic, and in generic licensing of HIV/AIDS medicines for export to poor countries. Canada also, along with the U.S., pioneered the Global Health Security Initiative (GHSI) in 2001. And Russia as host of the G8 at St. Petersburg in 2006 held the first G8 meeting for health ministers. Developing country governments are often a great source of innovation, even when they lack some of the capabilities that those in rich countries assume are necessary to provide public health. Singapore, in the case of SARS, and Zimbabwe, in the case of HIV/AIDS, were innovators at home and led the way for others abroad. Thailand’s ‘trusted person’ system worked well for malaria and could for avian influenza. Bennett concludes that Thailand, Chile, and even Cuba are innovating in ways that the North could borrow and benefit from. Developing country leadership arose internationally in the case of tobacco, as Collin and Lee show. Most broadly, as Forman notes, two thirds of all national constitutions include health and health related rights. But, as Khoubessarian concludes, there is still a northern bias in the many global health initiatives that have come. Other vibrant innovators include international institutions of a broadly multilateral, plurilateral, and regional character, as formal organisations or as informal institutions or initiatives, and as operated by leaders, ministers, or officials. Appendix 16-3 displays the leading actors in the vast array of international institutions involved in global health governance now. Several others, such as the Asia-Pacific Economic Cooperation (APEC) forum, the Security and Prosperity Partnership of North America (SPP), the Commonwealth, and la Francophonie could easily be
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added to the list. Virtually all of them have been important innovators in recent years. Standing out are the WHO itself, the G8, the Association of South East Asian Nations (ASEAN), and the many disease-specific multi-stakeholder initiatives. The World Trade Organization (WTO), the World Bank, and the UN are increasingly involved. As these initiatives highlight, innovation in global health governance has become a multiple-source, multi-level affair. Actions This large number and broad array of innovating actors has generated an ever greater number and type of innovations. Appendices 16-4, 16-5, and 16-6 provide an inventory of the innovations cited in this book. This field includes individual instruments, ranging from physical inventions such as the advent of new medicines to policy innovations, including developments in international law, techniques of summit leadership, and resource mobilisation. These innovations have extended into the high politics of war and peace. Innovation has arisen in more embedded form in the institutions of global health governance, at the international, national, and subnational levels. It is also evident in the private and civil society sectors, including the rise of voluntary standards, and in the media, with the spread of the internet. Perhaps the greatest outburst has come in the realm of ideas that have been newly crafted and have had a global appeal. As Appendix 16-7 indicates, ideational innovation has come in the new linkage forged between health and a broad array of other values, including peace and security. There has been a real if incomplete revolution in priorities, as health has progressively been given equality and precedence over other social, economic, and trade values, and even conflict. Along with this rearrangement of priorities in these newly forged relationships has come a host of new principles, embracing specific to general definitions of rectitude and ranging from process to substantive. Also evident but still modest have been innovations in the creation and acceptance of health as a right and as a responsibility. And the world is only beginning to define new concepts such as health as a global public good, global health security, and heath diplomacy. Targets The targets of these innovations have been behind and at the borders of both originating and destination states. They have increasingly aimed to deal with the disease at its source. There has been a move from point-specific, local, single, instrumental measures to global, systemic ones. This move to confront the challenge at the source was seen in SARS the case of when the WHO sent its own teams into China to assess the government’s containment measures there. Action in the national court system was important in improving access to HIV/AIDS medicines in South Africa, as Forman describes. At the same time, efforts at the border to improve screening and impose trade sanctions remain relevant. Innovation in holistic global approaches is only just
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beginning. As Khoubessarian notes, global health initiatives still focus on highprofile diseases. And while private firms and national governments have been targeted, the free migration of health professionals shows that their right to move anywhere trumps the right to health of those who remain in the highly afflicted locales and countries that those departing health workers leave behind. Processes The creation of new instruments, institutions, initiatives, and ideas aimed at several targets has been a highly conscious and strategic enterprise, usually requiring a deliberate, sustained effort against active resistance from powerful actors on many fronts. There may be isolated cases where innovation has come without conscious intention, as Kamradt-Scott allows may have been the case in the WHO’s decisive action in response to SARS. But overwhelmingly innovation is not accidental. Workarounds or accidental discoveries in the lab may still work in the physical world but seldom do in the political realm. And even in the physical realm, as with the initiatives on the International AIDS Vaccine Initiative (IAVI) and GAVI (formerly Global Alliance for Vaccines and Immunisation) and the cases of HIV/AIDS and avian influenza, ‘big project’ strategic science by global networks over many years is required to produce and deploy the vaccines that will meet the goal of prevention. In the social and policy sciences, innovation has required not only sustained epistemic effort to identify new facts and causal connections but also a political struggle to help discover the needed new knowledge and give it practical effect. As Bennett notes, even such basic elements as new statistics are still needed. The recent revision and reduction of the number of those infected with HIV/AIDS globally confirms the powerful political impact that raw data and their interpretation can have. Along with conscious, calculated, cumulative effort, there has been much innovation in the comprehensiveness, communication, cooperation, coordination, coherence, compliance, and capacity with which public actors respond to the new challenges. The greatest innovation has come in comprehensiveness, as more actors, disciplines, and policy considerations are involved in determining a response. In response to SARS, the WHO assembled a wide array of scientists, epidemiologists, and professionals in a linked network. ASEAN has reached out to China on SARS and the G8 to the Outreach Five of China, India, Brazil, Mexico, and South Africa as well as to several African partners on public health overall. The WHO is now connected to the many other multilateral bodies in its ongoing work and at times to the annual G8 summit. Yet there remain weak links in the network, such as Taiwan, still shunned in the cases of SARS and avian influenza, and failed and failing states in the cases of HIV/AIDS and polio. And in the UN’s central climate change negotiations, health and the WHO have largely been left out. Communication has seen much innovation. In response to SARS, the WHO and the Chinese government used the media to get their message directly to a mass audience, and the WHO issued geographically specific travel advisories and global alerts. Civil society has now become active in many centres of global health
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governance and provides data and analysis directly to the WHO. After the challenges of SARS and HIV/AIDS, improved surveillance and reporting, transparency, and private and public criticism—rather than secrecy, silence, and shame—have become the order of the day. Mobile communication and training for crisis communication have been expanded. The Global Public Health Intelligence Network (GPHIN) is now in place. And the WHO holds public hearings, face to face and on the internet. Cooperation and coordination are following. There is greater clarity about the roles of the relevant actors. SARS saw the centralisation of decision making at the national level in Canada and at the international level in the WHO, as Bennett and Kamradt-Scott emphasise. SARS and avian influenza have led to greater regional cooperation among the Pacific Rim countries. The WHO, the Food and Agriculture Organization (FAO), and the World Organisation for Animal Health (OIE) have together produced a master plan for animal health, as White and Banda note. Global health initiatives are producing many coordinated, coherent campaigns to attack individual diseases, providing a focal point for many to mobilise, contribute, and monitor, as Khoubessarian charts. The new concept and process of health diplomacy are breeding coherence among politically feasible, economically attractive, epidemiologically informed, and ethically sound measures, as Dal, Sunderland, and Drager show. Compliance is also seeing innovation, if in an uneven way. Global health initiatives make monitoring of commitments and results easier, although not adequately yet. Methods to measure the health impacts of trade and trade agreements are well behind the comparable work in the field of trade and the environment (Kirton and Maclaren 2002). The human right to health is not fully monitored. In the G8, priority placement and one-year timetables improve compliance, but these techniques are rarely used. And in tobacco, where many have signed but few have ratified the FCTC, the compliance gap remains. Capacity has been infused by innovation in several ways. In the case of SARS, the WHO displayed adaptive resilience by rapidly redeploying resources to combat the disease. In both China and Canada, much new capacity was created during and in the wake of the disease, as Price-Smith, and Huang as well as Bennett describe in detail. In Brazil, the fight against HIV/AIDS creatively called forth new forms of capacity from civil society. An increase in surplus capacity is also evident, beyond the increase in the monies raised for old instruments such as ODA. One such innovation is debt relief for the poorest countries on condition that they use the forgiven payments to improve their citizens’ health. Another is the way the WHO called upon its residual constitutional authority to respond to SARS. But the underlying healthcare systems of many countries remain underfunded and ill designed, as Khoubessarian and others note (see, for example, Garrett 2007). And the 2007 G8 summit in Heiligendamm, Germany, was driven off its intended focus on strengthening such healthcare systems by the popular demand and political appeal of mobilising yet more money for a few high-profile diseases. Dealing more creatively with aid absorption and long-term targeting are tasks that remain (Fratianni, Savona, and Kirton 2007).
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There is now a veritable profusion of innovation, generating considerable competition and choice. The task is not only to increase the supply, but also to assess which of the many new innovations actually work in the intended or in an otherwise effective way. Only then can the best be selected, spread, institutionalised, and built upon as the foundation for a new global health system in the years ahead.
Systemic Responsiveness Not all innovations work well in the predicted and desired way. Some, such as the still outstanding vaccine against HIV/AIDS, arrive too late, if at all. Others, such as the human right to health, sound good in principle but are poorly complied with in practice. Other intuitively attractive ideas may also not be fruitful, such as using the G8 summit to mobilise money when it makes commitments for heath causes, as this does not significantly increase member governments’ compliance in the following year. And the entire repertoire of recent innovation is self-evidently inadequate given the high cost in human life and environmental, social, economic, and security values that the contemporary globalised health challenge creates. It is thus important to assess the responsiveness, appropriateness, and effectiveness of the innovation that the current system of global health governance now brings. Only on such a basis can the many and sometimes conflicting policy recommendations offered by the contributors in this volume be evaluated for the value, priority, and urgency they contain. Responsiveness Responsiveness refers to the speed with which the desired innovations come, both before and after the standard responses have failed. Here the spectrum runs from nonexistent or very slow innovation through timely and immediate novelty to proactive and preventive measures to solve the problem before it arises and spreads. At times innovations do come before the outbreak or spread of the disease. As Kamradt-Scott shows, in 1995 WHO members instructed the organisation’s bureaucracy to revise the IHR. The process of revision and replacement was still underway when the SARS epidemic broke out, but it helped give the WHO the justification to mount a fast response. Lo notes that preparedness, while absent in the case of SARS, has led to precautionary action before the next case of pandemic avian influenza. Similarly, the 1995 BSE outbreak led the European Union to act against a recurrence of either it or another similar disease. But still the precautionary principle, which has flourished in global environmental governance, is more often applauded than applied in the field of global health. When the challenge arises or reaches a critical threshold of cumulative spread, there is a wide range in the rapidity of the innovative response. During the SARS oubreak, Hong Kong, due to its earlier experience with avian influenza in 1997, moved quickly, as did Singapore and the WHO. But China took three months before it moved decisively with new openness. Canada underestimated the speed with which
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SARS could spread. On H5N1 avian influenza, Indonesia was slow even to admit the outbreak of the disease. On HIV/AIDS in southern Africa, there has been great variation in the rapidity of the innovative response, with Zimbabwe moving early and South Africa very late. The new concept of health diplomacy has in principle brought in simultaneity, by demanding that health, diplomatic, economic, and ethical considerations all be assessed and integrated at the start. However, it has yet to be decisively deployed to assess the health effects of trade liberalisation agreements in advance, in a way that has become routine in the environmental field. At times the innovations come long after the challenge, in the face of repeated failures from the old routines. The instrument of ODA and the institution of the G8 have been slow to adjust to the magnitude of the HIV/AIDS pandemic. The campaign against polio seems never-ending. The legal right to place health over economic values is still very slowly moving ahead. The global health initiatives that were designed to speed up solutions have yet failed to deliver or come close to any striking success. And in the complex, highly regulated world of health, it takes considerable time before research, development, clinical attempts, regulatory approvals, marketing, and field delivery of new medicines can come. Sometimes adequate innovation is so slow that it never seems to arrive. Creating early warning systems, reliable statistics about population and their health, healthcare systems in poor countries, a global regime for the migration of health professionals, and sustained compliance with G8 health commitments and other international health regimes seem far away. And the post–September 11 anthrax attacks in America,seems to have gone away for the moment, but, without adequate innovation, may return at any time to kill again—like the Black Death in Europe did in the 14th century. Appropriateness The appropriateness of these innovations similarly shows wide variation. This comes in their diagnosis and analysis, agenda setting, resource mobilisation, targeting, instrumentalities, and assignment and acceptance of responsibility. There have been some notable successes, such as the WHO responding rapidly, forcefully, and proportionally to SARS, as Kamrandt-Scott concludes. But the WTO’s response has been inadequate to health needs in the case of HIV/AIDS. Cohen-Kohler notes that globalisation can impose inappropriate standards and designs and that more carveouts are needed as a result. Yet South Africa’s reliance on the traditional knowledge and practice such as beetroots and garlic, rather than proven ART, was massively inadequate to control its HIV/AIDS pandemic. Effectiveness Effectiveness is where the record of innovation has been least impressive. This is true whether effectiveness is measured by the human lives saved, extended, and improved or more broadly by the environmental, social-demographic, economic, and political security values enhanced.
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By the standards of the 1918 Spanish influenza, which killed twice as many people as died in combat during the four year war before, SARS can be considered a success. It was contained within ten months. On 5 July 2003, when the WHO announced the end of the outbreak, only 774 of the 8096 infected individuals had died. Yet the high fatality rate in most countries, including 17 percent in well-equipped Canada, gives no ground for complacency. Nor does avian influenza, where even fewer have yet died from a disease that continues to spread. And while polio cases worldwide have declined dramatically since Rotary started its work, the disease is still not gone for good. It was more than two decades ago, in 1988, that the World Health Assembly (WHA) set its goal of eradicating polio from the planet by 2000. The greatest killers are HIV/AIDS and tobacco, despite the many innovations that have come from so many over a very long time. In 2007 an estimated 2 million people worldwide died of AIDS, of whom 38 percent lived in southern Africa alone, in countries where life expectancy had declined to under 50 years (UNAIDS 2008, 15, 32, 46). While recent statistical revisions have lowered the projections, many feel that AIDS kills even more, as deaths are commonly attributed to other associated and less stigmatised diseases. And even in Zimbabwe, the one country in southern Africa that has been successful in fighting HIV/AIDS, the current economic crisis may destroy these hard-won gains. Even with the cost of ART coming down from US$15 000 for an annual supply to as low as US$148, only an estimated one sixth of those infected in southern Africa receive the drugs. The WHO’s bold promise in 2003 to put 3 million in treatment by 2005 clearly failed. And at the current rate of innovation, the G8’s more ambitious 2005 promise to achieve universal access to affordable treatment by 2010 will also not be met. These failures of innovation have considerable collective costs. Environmental costs are evident in the slaughter of domestic and wild animals in the face of SARS and avian influenza. Demographic costs come with the declining populations of AIDS-devastated southern African countries such as Swaziland and the migration of healthcare professionals from the poor South to the rich North. Social cohesion is eroded when some are shunned as in the case of SARS, and when many flee infected cities, such as Surat in 1994 and Beijing with SARS in 2003. The economic costs are also major and multifaceted. SARS struck hard on the demand side, reducing local economic activity and tourism in infected areas. While economic growth rebounded swiftly and strongly in Asia, Toronto was slower to come back. Avian influenza has cost as much as US$60 billion thus far. A real pandemic is likely to inhibit trade and foreign direct investment (FDI) and depress national economic activity on the supply side. Indeed, an estimated 40 percent of the U.S. labour force could go missing if an influenza pandemic strikes. AIDS in southern Africa costs countries up to 5.8 percent of their gross domestic product (GDP). At the micro level it has led firms to mount their own treatment programmes in order to have their own trained if infected labour forces work as long as they can. In the political security realm, there are considerable costs as well. SARS caused riots against quarantine centres in Beijing. AIDS reduces state capacity by diverting government resources and killing officials throughout southern Africa. At
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the international level the G8 club of the most powerful leaders of the most powerful countries in the world does deliver on most of its governance functions, but its members’ compliance with its commitments varies by year, by country, and by issue. And while the new physical challenges have yet to become a security challenge of the dimensions they were in 1918 or in ancient Athens, the real connections and costs are becoming clear. This analysis of system responsiveness produces three propositions to guide further empirical and ultimately policy work. The first hypothesises that the more pathogenic and contagious the disease, the greater the supply side and the demand side shocks and costs will be. The second suggests that large open countries are likely to be hit with quarantines, and thus be induced to cope with them in innovative ways. The third proposes that the openness of the political regime and the size of the state determine the effectiveness of the governance response.
Systemic Transformation In the face of such large and widespread costs there is considerable prima facie evidence that much more innovation is urgently needed than that which has arisen to date. Indeed, to achieve it, the global community may need to replace the Westphalian principles and practices it has long relied on for global health governance with some as yet only dimly identifiable post-Westphalian and even anti-Westphalian forms (Ruggie 1993). Neo-vulnerability The first sign of this post-Westphalian transformation is the rise of the new vulnerability to replace relative capability as the driver of how an anarchic, competitive, statecentric system works. This new vulnerability flows from non-state sources, through uncontrolled processes that flow into other countries to assault their human security, no matter how great the capability of the assaulted country to provide a defence. In the five cases explored in this book there are many signs of the power of this new vulnerability and of the transformation from a world of relative national capability to one of equalised global vulnerability. In the face of the SARS coronavirus that invisibly and quickly spread from Asia into North America, the sealed hospitals of a highly capable Canada compounded the harm to innocent civilians in Toronto, whereas the open-area hospitals of a much less capable Vietnam did not. With the world economy becoming more dependent on China’s industry in a globalised production system, an avian influenza pandemic that starts there or elsewhere in Asia could quickly cripple even the most powerful countries in the world, with those that are most open being hit the most. Indeed, some research shows that the most capable countries are also the most vulnerable to an avian influenza pandemic, with the United States leading the Organisation for Economic Co-operation and Development (OECD) and China, Hong Kong, and Singapore coming first in Asia (Newcomb
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2005, 6). The openness bred by globalisation multiplies global disease, as it makes them travel faster and further around the world. And the new vulnerability can lead back to harm the old, with soldiers and civilians whose immune systems have been weakened by disease are consequently more susceptible to attacks from chemical and biological weapons. While all countries share this intensifying equality of the new vulnerability, it often takes a shock, or several, to inspire innovation in response. Price-Smith and Huang show that a punctuated equilibrium (PE) model of shock-driven innovation, far more than the functionalist or epistemic community alternatives, defined the cadence of innovation in the SARS case. Those hit by second or subsequent shocks were the leading innovators, with the 1997 avian influenza aiding Hong Kong’s response to SARS in 2003. The Asian financial crisis of 1997 and the environmental haze that came later fuelled Asian regional cooperation in response to SARS, as it made even China recognise how vulnerable it was to these new threats. And the shock of SARS helped highly afflicted countries such as Canada innovate preventively against avian influenza. Yet shocks do not inspire innovation in all cases. Although the spread of HIV/ AIDS into North America and Europe inspire the G8 to take up the subject, the disease’s move into Russia and Eurasia led Russia as G8 host in 2006 to make health one of the G8’s three priority themes, such shocks did not lead the G8 members to comply with their health commitments. Nor were single or sequential shocks necessary to drive the process of innovation in the case of access to AIDS medicines and tobacco control. While catastrophe often spurs innovation when it leaves behind enough capacity, leadership and civil society action can produce innovation before true disaster comes. Innovativeness Does such innovation, however driven, become embedded as a dynamic, selfsustaining, expanding force in a reformed global healthcare system or does it yield only a set of specific innovations to treat the crisis and challenge at hand? The PE model suggests that innovation has a short self-life, with the innovative instinct rapidly falling off once the current danger has passed. The one-time innovations become standardised into new routines, and the innovative urge fades. But how much has innovation turned into what might be termed innovativeness, where the entire system shows high degrees of reflection, learning, acceptance, spread, and institutionalisation of new lessons, and a permanent culture of innovation? There are some cases of innovative attrition, notably in avian influenza. Here some are responding slowly and slightly, respite the shock of SARS. And the innovative impact of SARS on WHO governance may be specific to that case and short lived, as Kamrandt-Scott concludes. But there is also much evidence of spreading, selfsustaining innovation in many forms. SARS inspired reflection and ‘lessons learned’ exercises in Canada with the political leaders and other countries brought in to share and spread the spirit and results. In Asia, lessons spread from Bangkok back
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to Hanoi. In China SARS created a broader move to openness, extending into the national security sphere when a submarine accident came. Institutionally, SARS drove China to become the first overall strategic partner of ASEAN. The Global Health Security Action Group (GHSAG) was created to address many health security issues, with a membership broader than the G7. The G8 and its Outreach Five partners, if not its one-off health ministers meeting, provided permanent expanded governance in the health field. The first Conference of the Parties to the FCTC in 2006 decided to develop two additional protocols. As Kamradt-Scott suggests in the case of SARS and Collin and Lee in that of the FCTC, the mere precedents can serve as tipping points for transformative change across a broader domain. The leadership role of the WHO, the involvement of civil society, the inspiration for national regulation on smoking across Europe even without formal ratification shows such proliferation. AIDS, tobacco, and the health diplomacy processes have generated greater concern with nutrition, obesity, and health services more generally. Innovations in several cases have driven a common effort to construct and put in central place new concepts, linked to meta norms and fields well beyond health, such as health diplomacy. As Bennett argues, the shock of SARS produced a learning culture in Canada. New Sovereignty Does this move to innovativeness mean that global health governance is now moving beyond its Westphalian confines already almost half a millennium old into a 21stcentury post-Westphalian system of globalised health governance? The challenge of disease, in the form of the recurrent plagues afflicting Europe during the 16th and 17th centuries, was an important force in creating the new political order of sovereign national states and thus the Westphalian international system that has dominated political life for the four centuries since (North and Thomas 1973; Jones 1981). Could today’s new health challenges also transform the old order into a new form of global governance that is anti-Westphalian at its core? The evidence in this volume suggests that the world is clearly moving in this direction. It is eroding the Westphalian pillars of states as the dominant actors, international institutions as a site for inter-state competition and sovereignty as the defining principle. Yet this transformation is still in a very early stage. The shape of the new order is unclear, contested, and uncertain. International and transnational multi-actor, multi-level networks have yet to become autonomous, legitimate, and authoritative centres of global governance on their own. And no single concept exists to replace the powerful attachment to the static, territorial, exclusive sovereignty of old. A new era defined by global rather than national sovereignty and security in health has yet to arrive. Still, states are no longer always the dominant actors, as they are now joined as important innovators in key cases by sub-national actors below, transnational actors across their boundaries, and international actors above. In all cases a multiplicity of actors has been involved in shaping responses. Many arose as innovators or catalysts for innovation by others. Within states, civil society and often the media stand out
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as driving change and providing disease surveillance, delivery, implementation, and overall legitimacy. With HIV/AIDS in Brazil and with polio, civil society actors and philanthropy provided the capacity that states clearly lacked. In the SARS case, less capable southeast Asian states effectively intervened in China’s domestic affairs. Still, China’s shunning of Taiwan shows the strength of the Westphalian formula, even in the face of clear risks to global health. And ultimately only national governments are accountable and thus responsible for the health of their own citizens and others inside and outside their own state. International institutions are arising as effective and legitimate innovators in a great diversity of forms. The WHO, the institution at the heart of the late 1940s outburst of functional international organisations, has shown many remarkable advances. In the case of SARS, it broke the old state monopoly by communicating directly with citizens and disseminating the results, without the state’s permission, to people around the world. Similarly, the WHO issued geographically specific travel advisories without the state’s consent. It sent an evaluation team to China without prior permission from the state. Rather than defer to states whose responses were clearly inadequate, and even though relatively few people actually died, the WHO became the world’s lead assessor, critic, and technical agency. Two years before SARS, the WHO had established the Global Outbreak Alert and Response Network (GOARN) to communicate directly with internet-connected and empowered citizens, bypassing their states. In May 2003 its members formally authorised the WHO to gather data from non-state actors. And the new IHR eroded the state monopoly on the reporting of pathogen-induced morbidity and mortality that the old ones had contained. It is thus understandable that David Fidler (2004) has proclaimed that SARS ushered in a post-Westphalian world. There are signs of such movement beyond the WHO and SARS. The WHO led on tobacco, where it brought in civil society and where its public hearings withstood counter claims that it was the instrument of a new northern-driven colonialism attacking the state sovereignty so recently won by the South. The WHO’s work on health diplomacy involves public hearings, including those held via the internet. The UN receives substantial sums not just from its state members, with their assessed and voluntary contributions, but also from non-state actors such as Rotary International for polio. Global health initiatives and the G8 mobilise money for the UN as well as address challenges directly, outside the UN. The monopoly on raising money for public goods—a core claim of the sovereign state—has gone, especially with Bill and Melinda Gates, Bill Clinton, and other celebrities getting into the global health governance game. The G8’s involvement in health has made national leaders global as well as state governors, and allowed them collectively to redefine their interests and identity in favour of the global public good. As Gro Harlem Brundtland recognised, only leaders can share their states’ sovereignty at first hand. Forman affirms the coercive and persuasive power of domestic and international law in the case of HIV/AIDS. There is thus much evidence that multi-stakeholder, multi-level governance, through networks of international institutions and nongovernmental actors, matter a great deal.
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At the same time, even the WHO in the case of SARS shows that the new power of international organisations is incomplete. Its innovations were in accord with the collective preference of its state members, even if not Canada and China at the time. Even with the revised IHR, states remain key to managing outbreak events. The SARS precedent may not extend to less lethal and communicable diseases such as malaria and HIV/AIDS. It has apparently not increased state compliance with hard law health regimes. While even the most powerful United States complies with its G8 health commitments along with the lesser members, the level of compliance is variable and still modest relative to the costs that the global community incurs from the current health governance regime. And Indonesia has recently wielded its sovereignty to threaten the WHO’s long-established virus-sharing regime. However, sovereignty as the defining principle of the global health governance system is eroding. Global health initiatives reduce the sensitivity to such erosions of sovereignty. The concepts of health as a human right, rights-based social action, and human security are all acquiring greater normative appeal and conferring legitimacy on responses and innovations that come from actors beyond the state. All make the individual rather than the state the ultimate referent of value, in a world where sovereign states are functionally no longer always the optimum actors to enhance human life and health. However, still unanswered is the question of who beyond the state has the responsibility to respond to the rights that all individuals in the world presumably possess, even if alternative rights cultures affirming collective duties are starting to enter the new normative mix. And more operational precepts such as ‘vaccinate the most vulnerable first wherever they may be’ are still a long way from assuming centre stage. The movement from state sovereignty, through rights of redistribution among states and people, to a new world of global rights and responsibilities for all individuals has only just begun. There is no clear sign that the latter will win out in the end. The same is true for its institutional equivalent of multiple, networked, effective, legitimate, embedded global governance. Even so, the transformational movement toward a world defined by global health sovereignty is clearly underway.
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Appendix 16-1: The Challenge-Response-Innovation Framework Process Physical Challenge Disease: communicable, non-communicable, unknown Source: state, human, natural, mixed, unknown Process: intentionality, targeting, guidance Pathway: within the global economic North, within the global economic South, South to North, North to South Impact: speed, spread, scale, visibility (outbreak versus attrition) Cause: biological, social-psychological, ecological, economic, social, political Public Response Actors: Actions: Targets: Process:
individuals, professionals, firms, nongovernmental organisations, states, international institutions cybernetic (repertoires, routines) or analytically rational ways source, at the border (quarantine), destination inclusiveness, comprehensiveness, communication, cooperation, coordination, coherence, compliance, capacity
Governance Innovation Actors: individuals to international institutions Actions: instruments, institutions, ideas Targets: physical source to the destination to which the disease has spread Process: accidental discoveries, trial and error, normal science, bigproject science System Responsiveness Responsiveness: non-existent, slow, immediate, proactive, preventive Appropriateness: diagnosis, resource mobilisation, targeting, instrumentalities, responsibility Effectiveness: lives saved and improved, social-demographic, environmental, economic, political, security System Transformation Neo-vulnerability: relative national capability to equalised global vulnerability Innovativeness: reflection, learning, institutionalisation, spread, cultural change New sovereignty: relative national resources, redistribution rights, global responsibility Governance: multiple, networked, effective, legitimate, embedded, global
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Appendix 16-2: Cases Core Cases Severe acute respiratory syndrome (SARS), 2002–03 Avian influenza, H5N1, 1996– HIV/AIDS, 1981– Polio Tobacco References Cases: Outbreak Events 5 BC Plague of Athens 6th C Plague of Justinian, Byzantine Roman Empire 14th C Bubonic plague (Black Death), Europe 1802 Yellow fever, Haiti 1918 Spanish influenza 1974 Plague of Surat, India 1976 Swine influenza H1N1, United States 1976 Ebola, Zaire, Sudan 1976 Legionnaires’ disease, United States 1986 Hepatitis C, Canada
1995 Bovine spongiform encephalopathy (BSE), Britain 1996 variant Creutzfeldt-Jakob disease, United Kingdom, North America 1997 Avian influenza, Hong Kong 2000 Dengue fever, Macao 2001 Bioterrorism (anthrax), United States 2004 Avian influenza LPAI, H7N1, Canada 2007 Drug-resistant tuberculosis, North America and Europe
Other Reference Cases Cholera Typhoid Malaria Tuberculosis Measles Diphtheria
Pertussis Tetanus Smallpox West Nile virus E. coli
Reference Cases: Non-Communicable Disease Aging (dementia) Heart disease Diabetes Obesity Cancer Cystic fibrosis Cardiovascular disease
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Appendix 16-3: International Institutions Involved in Global Health Governance Multilateral Organisations Food and Agriculture Organization International Labour Organization International Monetary Fund United Nations United Nations International Children’s Fund (UNICEF) Joint United Nations Programme on HIV/AIDS (UNAIDS) United Nations World Summit, 2005 United Nations Security Council Debate 1999 United Nations Conference on Trade and Development (UNCTAD) United Nations Environment Programme (UNEP) World Bank World Food Programme World Health Organization World Organisation for Animal Health (OIE) World Trade Organization Agreement on the Application of Sanitary and Phytosanitary Measures Agreement on Technical Barriers to Trade Agreement on Trade-Related Aspects of Intellectual Property Rights General Agreement on Trade in Services Informal Institutions G8 G8 health ministers meeting G7/8 finance ministers forum Global Health Security Initiative Multi-stakeholder Initiatives Bill and Melinda Gates Foundation, 2000 Clinton Foundation HIV/AIDS Initiative, 2001 Codex Alimentarius Commission GAVI (formerly Global Alliance for Vaccines and Immunisation)������ , 2003 Global Fund to Fight AIDS, Tuberculosis, and Malaria, 2001 Global Polio Eradication Initiative International AIDS Vaccine Initiative (IAVI) Polio Advocacy Group, 2001 PolioPlus, 1985 Roll Back Malaria, 2000 Smallpox initiative, 1967 Stop TB Partnership, 1998–2000 Therapeutic Solidarity Initiative WHO ‘3 by 5’ initiative, 2003
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Regional Organisations Association of South East Asian Nations (ASEAN) Health ministers Emergency summit European Union Pan American Health Organization (PAHO)
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Appendix 16-4: Instrumental Innovations in Global Health Governance Instruments Physical Artemisinin-based anti-malarial drugs Antiretroviral treatment for AIDS, 1996 Policy International law International Health Regulations (IHR) Revisions, 2005 Framework convention with substantive obligations, not subsequent protocols Opt-out provision Safety valves: selective disengagement from standards for developing countries Informal techniques of summit leadership Priority placement by leaders (G8) Money mobilised (G8, global health initiatives) Specified agency Targets Timetables (Single year, multi-year) Universal access to antiretroviral treatment by 2010, 2005 (World Health Organization, United Nations General Assembly, G8) Remit mandates G8 body Core international organisation (World Health Organization) Other international organisation Past promises Monitoring Regular replenishment conferences (International Development Association, Global Fund to Fight AIDS, Tuberculosis, and Malaria) ‘Days of Tranquillity’ cease fires for polio vaccination Trade–health tool and workbook
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Appendix 16-5: Institutional Innovations in Global Health Governance World Health Organization (WHO): Commission on Macroeconomics and Health Global Outbreak Alert and Response Network (GOARN), 2000 Public hearings on tobacco, 2000 Data collection from non-state actors, 2003 Global alerts issued, 2003 International Health Regulation (IHR) Revisions, 2005 Framework Convention on Tobacco Control (FCTC) Intergovernmental Working Group on Public Health, Innovation, and Intellectual Property (WHO) Web-based public hearings Commission on Intellectual Property Rights, Innovation, and Public Health World Bank HIV/AIDS Department Multi-Country HIV/AIDS Program for Africa Curbing the Epidemic, 1993 United Nations Security Council’s designation as threat to security, 2000 World Summit, 2005 Joint United Nations Programme on HIV/AIDS (UNAIDS) Economic and Social Council (ECOSOC) General Comment 14 (The Right to the Highest Attainable Standard of Health) World Development Report, 1993 United Nations International Children’s Fund (UNICEF) Tobacco and the Rights of the Child, 2001 (with the World Health Organization) World Trade Organization (WTO) Declaration on the TRIPS Agreement and Public Health, 2001 Decision on compulsory licensing, 2003 G8 Global Fund to Fight AIDS, Tuberculosis, and Malaria, 2001– (with United Nations) Health ministers meeting, 2006 Association of South East Asian Nations (ASEAN) ASEAN + health ministers Emergency summit ASEAN-China special leaders meeting ASEAN Fund against SARS Intergovernmental Global Health Security Initiative (GHSI), 2001–
Continued…
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Inter-institutional WTO observer at WHO WHO observer on WTO’s Agreement on the Application of Sanitary and Phytosanitary Measures, Agreement on Technical Barriers to Trade, General Agreement on Trade in Services (GATS), and Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) WHO-WTO joint missions, training sessions, senior-level meetings Multi-institutional Initiatives Smallpox initiative, 1967 PolioPlus, 1985– Stop TB Partnership, 1998–2000 Bill and Melinda Gates Foundation, 2000� – Roll Back Malaria, 2000� – Clinton Foundation HIV/AIDS Initiative, 2001� – Polio Advocacy Group, 2001 GAVI (formerly the Global Alliance for Vaccines and Immunisation)������ , 2003 WHO ‘3 by 5’ initiative, 2002 Codex Alimentarius Commission Global Polio Eradication Initiative Therapeutic Solidarity Initiative International AIDS Vaccine Initiative������� (IAVI)
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Appendix 16-6: National Innovations in Global Health Governance National Governments United States President’s Emergency Plan for AIDS Relief (PEPFAR) Foreign Aid in the National Interest, 2002 Democracy, Prosperity: Aligning Diplomacy and Development Assistance, August 2003 United Kingdom UK International Priorities: A Strategy for the FCO, 2003 ‘Eliminating World Poverty: Making Globalisation Work for the Poor’, 2000 Canada National Advisory Committee on SARS and Public Health Public Health Agency of Canada (PHAC) Chief Public Health Officer Global Public Health Intelligence Network (GPHIN) Canada-Asia Regional Emerging Infectious Disease Initiative Canadian Influenza Pandemic Plan Bill C-9 on Export of Medicines International Policy Statement, 2005 Swaziland National Emergency Response Council on HIV/AIDS Botswana National AIDS Council Coordinating Agency Routine AIDS testing, 2003 Zambia National HIV/AIDS/STD/TB Council HIV/AIDS Act, 2002 Zimbabwe National AIDS Coordination Programme, 1987 AIDS levy on all taxpayers Voluntary counselling and testing programmes South Africa Operational Plan, November 2003 Nelson Mandela’s announcement of his son’s death from AIDS, 2005 Private Sector International Tobacco Products Marketing Standards, September 2001 AA1000 Social Reporting Process Antiretroviral generic treatments from GlaxoSmithKline Anglo American HIV/AIDS programmes
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Appendix 16-7: Ideational Innovations in Global Health Governance Linkages Population health (Canada), 1974 Socioeconomic determinants of health Health and development Health and children Health and human rights Health and gender, 1999 Health and international peace and security, 1999 Priorities Millennium Development Goals (MDGs) as comprehensive, coherent, development-oriented set Partnership on a multi-sectoral, multi-stakeholder basis for mutual benefit (Framework Convention on Tobacco Control [FCTC]) Social over economic development (China and severe acute respiratory syndrome [SARS]) Health over trade (‘Patients over Patents’; HIV/AIDS, not FCTC) Health over conflict (‘Warfare to Welfare’; polio) Health over all Principles Health for all at highest standard Prevention Duty of care (World Health Organization [WHO]; severe acute respiratory syndrome [SARS]) Full support for multilateral organisations Collective responsibility on SARS (Association of South East Asian Nations [ASEAN] Bangkok summit) Access, affordability, accountability, transparency, inclusiveness, comprehensiveness, coherence Vaccination for the most vulnerable first wherever they may be (World Bank) Precautionary principle Rights Human right to health (versus the right of people and healthcare workers to flee) Compulsion versus voluntarism Responsibilities Global health responsibility to provide care (responsibility to protect health) Corporate social responsibility Concepts Global public goods Global health security (human security) Health diplomacy
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Index ‘3 by 5’ initiative. See World Health Organization: ‘3 by 5’ initiative 301 Military Hospital 87 1918 Spanish influenza. See influenza: 1918 Spanish AA1000 Social Reporting Process 339 Abbott’s Laboratories 195 Abuja Declaration 160 access to care 15, 49, 167 HIV/AIDS 173 access to medicine 15, 51, 58, 116, 179–190, 193–203, 254, 315–316, 318, 327 Africa. See Africa: access to medicine accountability 53, 61, 93, 110, 113, 314 Achmat, Zackie 164 Action Plan for Health and Nutrition 298 Action Programme on Essential Drugs 189 advocacy 16, 106, 111, 114, 117, 122, 123, 160, 164, 166, 188, 197, 198, 199, 202, 203, 211, 215, 216, 221, 225, 226, 227, 228, 231, 232, 233, 234, 236, 246, 258 Afghanistan 93, 214 Africa. See also southern Africa access to medicine 194, 196–197 avian influenza 43 borders 98 G8 261, 321 Global Fund to Fight AIDS, Tuberculosis, and Malaria 301 gross domestic product 325 health workforce 296 HIV/AIDS 51, 155, 198–199, 199–200, 258, 286, 290 economic impact 325 polio 211, 214 tobacco control 224, 225 African National Union–Patriotic Front 41 African Union 215 agency slack 12, 64, 65–66, 66, 317 aging 262, 266, 278, 333 Agreement on Technical Barriers to Trade 249, 251, 254, 256, 334, 338
Agreement on the Application of Sanitary and Phytosanitary Measures 110, 249, 251, 254, 256, 334, 338 Agreement on Trade-Related Aspects of Intellectual Property Rights 16, 116, 180, 181–190, 195, 197, 198–199, 202, 249, 251, 254, 256, 334, 338 Agri-Food and Veterinary Authority (Hong Kong) 89–90 agriculture 5, 14, 58, 105, 107, 108, 111, 112, 115–116, 117, 120–121, 123, 135, 226, 279, 281, 314 aid 14, 53, 56, 61, 111, 112, 114, 115, 121, 122, 123, 158, 173, 174, 179, 196–195, 199, 211, 212, 215, 230, 234, 236, 251, 254, 259, 261, 277, 285, 287, 288, 289, 292, 293, 295, 297, 298, 299, 303, 314, 322, 339. See also official development assistance airport 90, 100, 315, 316 alcohol 4 Alexandra, South Africa 165 Ali, Harris 102 Alkire, Sabina 181 Alma Ata 233 Almond, Douglas 139 Alvarez, Jose 70 Amoy Gardens (Hong Kong) 89 Angell, Marcia 180 Anglo American 166, 339 Angola 214 animal health 60, 110, 111, 112, 121, 130, 185, 311, 317, 322 animal rights 316 animal slaughter 325 Annan, Kofi 301 anthrax 25, 113, 291, 311, 324, 333 antibiotics 116, 117, 120, 132, 194 antiretroviral treatment 15, 58, 93, 168, 171, 173, 175, 189, 195, 196, 197, 198, 199, 201, 258, 324, 325, 336, 339 Botswana 157
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South Africa 162, 163–165, 166–167, 167, 169, 170, 171, 172 Zambia 158 Zimbabwe 160, 161 APEC 319 aquaculture 115, 116 Argentina 226, 236 artemisinin 194, 336 ASEAN 38, 39, 320, 321, 328, 335, 337 ASEAN +3 38 severe acute respiratory syndrome 37–39, 321, 328, 337 Asia 13, 38, 83, 90, 92, 93, 98, 135, 138, 211 access to medicine 194 avian influenza 84, 87, 286, 318–319, 326 economic impact 123 outbreak 130 Canada 83, 100 discrimination 140, 313 gross domestic product 30, 135, 137–136 HIV/AIDS 156 infectious disease 13, 84, 85–92 severe acute respiratory syndrome 37–39, 85, 87, 101, 140, 139, 325, 326–328 Asia-Pacific Economic Cooperation 319 Asia Pacific Foundation of Canada 101 Asia Pacific region 101. See also Pacific Rim Asian Development Bank 30, 57, 135, 137 Asian financial crisis 37–38, 39, 327 Association of South East Asian Nations. See ASEAN Atlanta 55 Australia 117, 228 Austria 102 authoritarianism 88, 94, 95, 101–102, 145, 201, 202–201 avian influenza 10, 13–14, 36, 44, 54, 56, 83, 83–103, 105, 106, 112, 113, 114, 119, 121, 122, 123, 248, 286, 310, 311, 312, 314, 316, 317, 318, 319, 323, 325, 326, 327, 333. See also H5N1 Asia 84, 286, 318–319, 322 case fatality rate 131 China 83, 92, 102 deaths 10, 107 economic impact 107–108, 108, 121, 123, 325
H5N1. See H5N1 H7N1 333 H7N3 108 highly pathogenic (HPAI) 108, 112, 113–114, 117, 124 Hong Kong 83, 87, 89–90 in humans 123 Indonesia 83, 324 low-pathogenic (LPAI) 108, 333 outbreak 97, 130 pandemic 97, 110, 117, 285, 317, 319, 326 prevalence 310 prevention 115, 117 response 87–89, 109, 327 source 10, 107–109 Taiwan 321 Thailand 83 transmission 106, 107–109, 123, 312 United States 103 vaccine 55, 117–118, 309, 321 Aztec 144 Baliamoune, Mina 266 Baltics 227 Baltimore, David 146 Bamako 112 Banda, Maria 314, 317, 322 Bangkok 38, 50 Baptist Hospital (Hong Kong) 89 Barry, John 131, 141 BAT 223, 226–229 bats 24 Bayne, Nicholas 259 Beaglehole, Robert 302 beef 116–117 beetroot 164, 169, 171, 172, 324 Beijing 29, 32, 35, 39, 40, 87, 91, 325 mayor 32, 87 Belarus 227 Belgium 140 Bennett, Carolyn 311, 315, 316, 317, 319, 321, 322, 328 Besada, Hany 313, 319 Bettcher, Douglas 237 Biersteker, Thomas 303 Bill and Melinda Gates Foundation 212, 286, 287, 334, 338
Index Bill C-9 on Export of Medicines (Canada) 188, 339 Bio Economic Research Associates 135, 138 bio-security 108, 112 biological weapons 9, 23, 114, 279, 281, 311, 312, 327 biomedical model 262 biotechnology 262, 278–281, 281 bioterrorism 5, 25, 56, 95, 113, 120, 124, 262, 266, 281, 291, 300, 311, 333 birds 84, 102, 121, 124, 130, 130, 131, 310, 311, 312, 313 Black Death. See bubonic plague Blackwell, Elizabeth 49, 50, 61 Bloche, M. Gregg 187 Bloom, Barry 43 Bloomberg, Michael 236 Blouin, Chantal 254 BMO Nesbitt Burns 135 Bolivia 212 borders 5, 9, 14, 31, 53, 94, 95, 96, 98, 112, 120, 129, 236, 245, 251–252, 288, 313, 314, 316 Botswana 15, 155, 156, 157, 164, 168, 170, 339 bovine spongiform encephalopathy. See BSE BP Amoco 228 Bradford, Colin I. 123 brain drain 4, 173, 293–294, 295, 296, 297, 299, 302. See also migration Brazil 51, 61, 183, 189, 224, 226, 235, 315, 321, 322, 329 Brazilian Institute of Social and Economic Analysis 122 Brent Spar 228 Bristol Myers-Squibb 201 British American Tobacco 223, 226–229 British Columbia 53, 100, 108 Broughton, Martin 227 Brown, Theodore 236 Brundtland, Gro Harlem 74, 75, 105, 220–222, 230, 233, 236, 315, 329 Brunei Darussalem 73 BSE 23, 26, 124, 310, 323, 333 bubonic plague 134–135, 137, 140, 141, 144, 145–146, 313, 324, 333 Bush, George W. 175, 224 Bush administration 303
383
business 56, 94, 95, 97, 135, 166, 172, 174, 259 Business Day 198 Buss, Paolo 246 Butler-Jones, David 54 Byzantine Roman Empire 145, 333 Cabinet Committee for Security, Public Health, and Emergencies (Canada) 93 Cambodia 38, 113, 212 Campbell, Bonnie 303 Campbell, Justice Archie 34 Canada 56, 26, 49, 84, 91, 93, 98, 102, 113, 122, 188, 316, 317, 319, 333 Asia 83, 100 avian influenza 106, 117, 327 crisis response 53 G8 260, 261, 271 Global Pandemic Influenza Readiness 50 health governance 53, 122, 339 health minister 34, 49 health workers 94, 98 House of Commons (Parliament) 95, 101, 102 media 92–94 minister of state for public health 50 official development assistance 286, 295, 298, 315 population health 340 preparedness 13, 54, 92–101, 110, 319 Senate 102 severe acute respiratory syndrome 12, 13, 24, 26, 27, 31, 32–35, 42, 99, 101, 312, 314, 317, 322, 323, 327 communication 52–54 discrimination 140 economic impact 32–33, 52, 86 prevalence 31, 310 response 34, 85–86 tobacco control 225, 235–234 tourism 33, 34 trade 108, 116 United States 98 World Health Organization 59, 73, 123, 330 travel advisory 34, 40, 317 Canada-Asia Regional Emerging Infectious Disease Initiative 56, 339
384
Innovation in Global Health Governance
Canadian Access to Medicines Regime 188 Canadian Food Inspection Agency 60, 108, 124 Canadian Influenza Pandemic Plan 84, 93, 339 Canadian International Development Agency 295, 298–299, 299, 315 Canadian Manufacturers and Exporters 97 Canadian Pandemic Influenza Plan for the Health Sector 93 Canadian Public Health Agency 213 cancer 4, 180, 194, 298, 312, 333 capacity building 112, 114, 118, 120, 252, 254, 256, 293, 294–296, 298, 299, 302, 316, 322 capitalism 94 cardiovascular disease 298, 333. See also heart disease Cardoso, Fernando Henrique 105, 112, 123–122 Caribbean 213, 214 Carter Center Guinea Worm Eradication Program 287 cats 91 Center for Global Development 303 Centers for Disease Control and Prevention 43, 53, 55, 59, 130, 135, 212 Central Statistical Office (Swaziland) 156 CESCR. See United Nations Economic and Social Council: Committee on Economic, Social, and Cultural Rights Chad 214 Chan, Anson 87 Chan, Margaret 84, 89, 91, 102 chemical weapons 144 Chen, Lincoln 181 Chicago 216 Chicken Farmers of Ontario 97 chicken industry 108 chickens 57, 91, 103, 107, 108, 113, 114, 115, 117, 124, 132, 311 slaughter 89–90 Chief Public Health Officer (Canada) 339 Chile 319 China 30, 33, 36–37, 41, 61, 83, 85, 78, 90, 91, 92, 102, 115, 133, 134, 138, 145, 146, 302, 329 ASEAN 38, 38–39, 321, 327, 328
avian influenza 83, 87, 89–90, 92, 103, 107, 115, 326–327 chickens 91, 103 crisis response 37 disease outbreak 67 gross domestic product 30, 115, 138 health minister 87 HIV/AIDS 37 human rights 200, 201 Law of Prevention and Treatment of Infectious Diseases 35 media 36, 90 Ministry of Health 31, 32, 35 National People’s Congress 35, 39, 90 polio 214 severe acute respiratory syndrome 12, 13, 24, 26, 72, 83, 84, 90, 92, 99, 108, 120, 142, 312, 314, 315, 317, 322, 328, 329, 340 discrimination 140 economic impact 29–30, 86, 139 effect on governance 33, 35–37 index patient 89–90 media 319, 321–322 outbreak 31, 63, 65, 111, 323 prevalence 31, 310 response 29, 32, 35, 90, 91–92 sociopolitical impact 140–141, 142 source 85, 311 travel 316 State Council 36, 37 State Secrets Law 32 tobacco control 224, 225, 226 tourism 29, 29–30 transparency 36, 87, 225 World Health Organization 13, 31, 72, 76, 77, 91, 320, 329, 330 China Center for Disease Control and Prevention 32, 35, 37 Chinese community in Canada 92, 102 Chinese University of Hong Kong 90 cholera 3, 40, 119, 333 Chrétien, Jean 34 chronic disease 3, 4, 298 circumcision 173 civet cats 24, 85, 311 civil liberties 13, 84, 101, 119. See also rights
Index civil society 7, 8, 14, 16, 41, 58, 85, 90, 105–125, 131, 133, 142, 143, 147, 166, 169, 170, 174, 193, 197, 248, 249, 250, 276, 291, 314, 317, 318–319, 320, 322, 327, 328, 328–329, 329. See also nongovernmental organisations AIDS 116 tobacco control 220, 224–225, 231, 232, 234, 235 World Health Organization 112, 321–322 Clement, Tony 33 climate change 120, 247, 313, 321 Clinton, Bill 318, 329 Clinton Foundation HIV/AIDS Initiative 286, 287, 334, 338 Codex Alimentarius Commission 236, 334, 338 Cohen-Kohler, Jillian Clare 314, 316, 318, 319, 324 Cold War 3, 4, 23, 311 Collin, Jeff 314, 316, 318, 319, 328 Colombia 214, 228 Commission on Intellectual Property Rights, Innovation, and Public Health 17, 183, 194, 247, 248, 337 Commission on Macroeconomics and Health 222, 230, 290, 337 Commission on the Future of Health Care in Canada 51 Commonwealth 319 communicable disease 6, 10, 13–14, 42, 64, 72, 89, 183, 194, 310, 312, 318, 330, 332 communications 14, 40, 42, 53, 54, 133, 159, 170, 174, 314, 322 communism 36 Communist Party of China 28, 32 compliance 12, 16, 17, 110, 111, 316, 317, 323, 332. See also G8: compliance Conference Board of Canada 135 Cooper, Andrew F. 200, 202 corporate social responsibility 111, 228–229, 318 Cortell, Andrew 12, 64, 65–66, 67, 68, 76, 77 counter-terrorism 9 Crenshaw, Kimberly 202 crisis response 7, 13, 18, 37, 53, 54, 68, 85, 88, 92, 101, 106, 147–148, 301–302, 316. See also preparedness
385
Crosby, Alfred 25, 131, 141, 143 Cuba 319 Cueto, Marcos 236 Curbing the Epidemic: Governments and the Economics of Tobacco Control 223, 231, 337 Curley, Melissa 303 cystic fibrosis 180, 333 Czech Republic 73 Dal, Benedikte 317, 322 DALY 60, 222 Daly, John L. 41 Daniels, Joseph 266 Darfur 200 Davies, David 235 Days of Tranquillity 214, 336 D’Cunha, Colin 34 deaths 3, 4, 5, 10, 30, 76, 97, 99, 325. See also mortality debt relief 322 Declaration on Partnership Against AIDS 165–166 Declaration on the TRIPS Agreement and Public Health 116, 186, 187–188, 195, 198–199, 248, 337 dementia 333 democracy 35, 36, 37, 84, 92, 94, 95, 101, 133, 140, 143, 162, 201, 257, 261, 296, 339 Democratic Republic of the Congo 214 dengue fever 4, 83, 92, 114, 333 Denmark 234 Department for International Development. See United Kingdom: Department for International Development determinants of disease transmission 15 determinants of health 4, 5, 6, 12, 50 social 106, 229 socioeconomic 262, 340 developed countries 42, 44, 61, 67, 121, 133, 144, 148, 183, 196, 213, 292, 294, 315, 319 preparedness 132–133, 147 tobacco control 224, 227, 231 developing countries 23, 25–26, 43, 44, 61, 111, 112, 114, 119, 179, 182, 196, 199,
386
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247, 248, 249, 251, 287, 293, 295, 297, 299, 317, 319. 336 access to medicine 193, 197, 202, 247 antiretroviral treatment 189, 197, 258 communicable disease 183, 194 drugs 183–184, 186, 188, 194–195, 195 Framework Convention on Tobacco Control 16–17 global health initiatives 285, 289 health workforce 110, 294 HIV/AIDS 197, 292 infectious disease 26–27 non-communicable disease 183, 194, 298 preparedness 132–133, 147 tobacco control 223, 224, 226, 227, 230, 231, 236 development 14, 106, 115, 118–119, 121, 129, 169, 183, 193, 211, 230, 232, 234, 248, 250, 252, 262, 263, 278–281, 289, 291, 293, 296, 297, 298, 299, 300, 303, 314, 315, 324, 340 development ministers 221 de Waal, Alexander 155 Dhanji, Hana 266, 273 diabetes 4, 180, 194, 298, 333 diphtheria 212, 333 diplomacy 9, 11, 30, 39, 44, 87, 91, 101, 121, 235, 261, 316, 324. See also health diplomacy celebrity 329 definition 11 disability-adjusted life year 60, 222 discrimination 99, 102, 140, 141, 166, 169, 173, 313. See also racism disease. See also chronic disease; communicable disease; infectious disease; non-communicable disease economic cost 332 eradication 17, 64, 67, 68, 69, 70, 72, 285, 287, 288, 289, 292, 295, 297, 299, 300 spread 4, 13, 14, 15, 25, 31, 40, 42, 55, 56, 58, 133–134, 311 history 24–26 Disraeli, Benjamin 34 Dlamini, Gugu 166 dogs 91 Douglas, Tommy 49, 50
Dover, Jeff 33 Doyle, Lindsay 266, 273 Drager, Nick 123, 254, 317, 322 Drahos, Peter 189 drug gap 179, 183, 194 drugs 3, 5, 41, 50, 98, 132–133, 186, 188, 194, 247, 248, 295, 297, 313, 320, 324. See also generic drugs anti-malarial 194, 336 antiviral 132, 145, 147 G8 278–281 illicit 98, 102 Drugs for Neglected Disease Initiative 183 ducks 107, 108, 113, 115, 124 E. coli 37, 50, 289, 333 early warning 114 earthquake 55, 56 East Africa 143 East Asia 40 avian influenza 43 gross domestic product 135 Eaves, Ernie 34 Ebola 119, 289, 333 economic development 33, 35, 36–37, 115 The Economist 286 ECOSOC. See United Nations Economic and Social Council education 3, 49, 93, 101, 113, 115, 118, 139, 168–169, 170, 173, 174, 232, 314 Edward III 144 Eliminating World Poverty: Making Globalisation Work for the Poor 339 England 140, 235 environment 4, 6, 14, 23, 37, 43, 44, 49, 93, 106, 108, 118, 120, 120–121, 121, 228, 247, 313, 314, 322, 323, 324, 325, 327, 332 epidemic attrition 30 Canada 84, 85 containment 43 economic impact 25, 84 mass response 28 security 25 Epidemic Projection 159 eradication of disease. See disease: eradication
Index Eritrea 214 Eurasia 106, 327 Europe 23, 25, 26, 84, 98 avian influenza 43, 107, 114 drugs 194, 196 HIV/AIDS 156, 196, 327 plague 140, 313, 324, 328, 333 polio 211, 214 tobacco control 226–227, 328 tuberculosis 333 European Coal and Steel Community 44 European Commission 55, 73, 124, 249 European Union 44, 113, 116, 198, 249, 314, 323, 335 beef 116–117 G8 261, 262 tobacco control 226, 234 Expanded Programme on Immunization 212, 213 faith-based organisations 6, 106, 119, 319 famine 107, 121, 155, 279, 281 Far Eastern Economic Review 30 farming 29, 56, 57, 84, 97, 106, 109, 111, 112, 113, 115, 117, 118, 121, 124 Fee, Elizabeth 236 ferrets 130 Fidler, David 12, 25, 33, 40, 41, 64–65, 66, 67, 68, 76, 138, 329 finance ministers 221, 226, 250, 260, 264, 265, 277, 314. See also G8: finance ministers Finland 73 fish 116 food 107, 121–122, 134, 136, 169, 236, 252, 256, 279, 281 Food and Agriculture Organization 57, 58, 110, 117, 123, 322, 334 food safety 109, 249, 254 food security 14, 97, 120–121, 247 foot and mouth diseases 36 Ford, Gerald 147 foreign affairs ministers 246, 248, 252, 314 Foreign Aid in the National Interest 298, 339 foreign direct investment 30, 25, 40, 231, 251, 325 foreign policy 229–234, 245, 245–246, 246, 247
387
Forman, Lisa 318, 319, 329 Foshan 32 Foster, John 258 foundations 17, 288, 292, 301, 314, 318. See also philanthropy Fourie, Pieter 169 Framework Convention Alliance 225, 234 Framework Convention on Tobacco Control 16–17, 219–237, 246–247, 319, 322, 328, 337, 340 Conference of the Parties 234, 236, 328 France 86, 117, 124, 140, 146, 198, 227, 234, 260, 261 la Francophonie 319 Franklin, Ursula 50, 51 Fraser Valley 108 G5. See Outreach Five G7 55, 266, 328, 334 G8 7, 17, 61, 258, 172, 262, 263, 264, 302, 319, 320, 324, 326, 334, 336, 337. See also Genoa Summit; Gleneagles Summit; Heiligendamm Summit; Hokkaido Toyako Summit; Kananaskis Summit; Okinawa Summit; St. Petersburg Summit Africa 261, 321 compliance 17, 257–266, 270–284, 317, 322, 324, 327, 330 catalysts 260, 262, 264, 265, 276–281 definition 261 scores 261–262, 265–266, 278–281 development 262, 263, 264 drugs 278–281 finance ministers 260, 264, 265, 277, 334 health governance 257–261 health ministers 264, 265, 271, 319, 328, 334, 337 HIV/AIDS 259, 262, 266, 278–281, 324, 325, 327 immunisation 278–281 money mobilised 257, 260, 262, 263, 265, 270–271, 277, 280–281, 329, 336 polio 262, 278–281 severe acute respiratory syndrome 262, 273–274, 275, 281 United Nations 258, 259–260 World Health Organization 257, 258, 260, 262–263, 264, 265, 277, 321
388
Innovation in Global Health Governance
G8 Research Group 266, 271, 273 G20 277, 302 garlic 164, 169, 171, 172, 324 Garrett, Laurie 132, 144 Gates, Bill and Melinda 6, 318, 329 Gates Foundation. See Bill and Melinda Gates Foundation GAVI 286, 288, 297, 321, 334, 338 geese 107 gender 319, 340 General Agreement on Tariffs and Trade 256 General Agreement on Trade in Services 248, 249–250, 251, 254, 255, 256, 334, 338 generic drugs 167, 170, 174, 186, 195, 195–196, 319, 339. See also drugs Geneva 216, 224, 226, 234, 247, 249 Genoa Summit 301, 319 Gerberding, Julie 43–44 Germany 86, 117, 124, 144, 198, 226, 230, 261, 319 tobacco control 224 GlaxoSmithKline 164, 339 Gleevec 195 Gleneagles Summit 199, 258, 265 global, defined 10 Global Alliance for Vaccines and Immunisation. See GAVI Global Fund to Fight AIDS, Tuberculosis, and Malaria 123–124, 158, 160, 170, 175, 199, 259, 262, 271, 273–274, 275, 278–281, 285, 286, 287, 292, 297, 301, 302, 303, 319, 334, 336, 337 global governance 24, 43, 246, 260, 285, 330 theories 11 global health initiatives 17–18, 285–303, 319, 321, 322, 324, 329, 330, 336 definition 287–289 Global Health Security Action Group 55, 59, 328 Global Health Security Initiative 124, 266, 319, 334, 337 globalisation 3, 4, 7, 9, 16–17, 43, 83, 85, 98, 106, 107, 109, 133–134, 180–181, 221–222, 245–246, 257, 258, 259, 286, 288, 301, 309, 326–327, 327, 328 Global Outbreak Alert and Response Network 13, 72, 76, 329, 337
Global Pandemic Influenza Readiness 57 Global Polio Eradication Initiative 334, 338 Global Public Health Intelligence Network 56, 322, 339 Glouberman, Sholom 51, 61 Goh Chok Tong 37, 38, 39 Gore, Al 198 governance 5–6, 8, 25, 31, 33–35, 43, 50, 51, 106–107, 129, 147, 288–289, 289, 299, 332 definition 11 severe acute respiratory syndrome 12 China 33, 35–37 Asia 37–39 Grand Challenges in Global Health 287, 303 Greece 161 gross domestic product 136, 137, 145 Asia 30 China 30, 45 Hong Kong 30–31 Ontario 33 Zambia 158 Guangdong 31, 35, 40, 85, 87, 102, 107, 108 Guangzhou 29, 31, 32 H5N1 10, 13, 23, 41, 43, 55, 84, 91, 107, 121, 123, 124, 130–131, 310, 311, 324, 333 animal health 84 birds 84 comparison with 1918 Spanish influenza 131, 136, 143, 144 drugs 84 Hong Kong 56, 87 Korea 83 poultry slaughter 91 southeast Asia 311 Thailand 84 World Health Organization 42 Haas, Ernst 26 Haemophilis influenzae type b 286 Haiti 146, 212, 333 Halstead, Joe 33 A Handbook of International Trade in Services 254 Hanoi 31, 50, 57, 91 Harvard School of Public Health 140 Health Canada 53, 54, 96 health, defined 10–11
Index health diplomacy 9, 11, 17, 245, 246–247, 252, 317, 320, 322, 324, 328, 340 definition 246 Health Emergency Communications Network (Canada) 93 Health for All 222 health governance 5, 15, 17, 39–41, 50, 84–85, 85–92, 101, 257, 259, 285–286, 287, 289, 291, 296, 298, 300, 300–301, 302, 309, 314, 318, 320, 321–322, 328, 330, 334–340 health ministers 60, 71, 124, 169, 221, 232, 248, 250, 251, 252, 264, 265, 314, 317, 319, 328. See also specific country; G8: health ministers ASEAN 335, 377 South Africa 164, 165, 166, 172 health ministers conference 50, 50, 57, 59, 105, 122 health security 25, 55, 109, 120, 124, 129, 247, 319, 320, 328, 334, 337, 340. See also security health workforce 8, 13, 31, 92, 94, 96, 98, 110, 121, 136, 147, 167, 173, 247, 252, 293–294, 296, 297, 298, 321, 324, 325 heart disease 180, 312, 333. See also cardiovascular disease Heiligendamm Summit 322 hemolytic uremic syndrome 289 Henry Kaiser Foundation 166 hepatitis B 286 hepatitis C 289, 333 Heymann, David 71, 73, 74, 123 highly pathogenic avian influenza (HPAI). See avian influenza: highly pathogenic Hirschman, Albert O. 35 HIV/AIDS 4, 10, 15–16, 23, 40, 41, 42, 43, 50, 57, 109, 114, 116, 119, 131, 134, 136, 143, 148, 155–175, 180, 184, 196, 197–199, 258, 259, 261, 263, 285, 286, 289, 291, 292, 296, 309, 310, 311, 315, 318, 321, 322, 325, 328, 330, 333, 340 access to medicines 16, 193–203, 314, 315–316, 318, 319, 320, 327 Africa 51, 155, 198–199, 199–200, 258, 286, 290 aid 15, 158, 172–173, 289–290, 303 as attrition epidemic 31
389 Brazil 51, 61, 315, 322, 329 children 156, 157, 158, 159, 160–161, 162, 167 China 37 civil society 318–319 comparison with 1918 Spanish influenza 143 deaths 15, 131, 194, 197, 325 eradication 168, 174, 292 Europe 156, 327 G8 259, 261, 262, 266, 278–281, 324, 325, 327 human rights 197–198, 199–200 impact 131, 168 economic 23, 30, 136, 325 political security 325–326 Latin America 156 Middle East/South Africa 156 North America 156, 327 official development assistance 298, 299, 300 origin 10, 290 pregnancy 163, 165, 167 prevalence 155, 156–157, 171, 310, 312 Africa 171 Botswana 157 South Africa 162 southern Africa 156, 156, 172 Zambia 158 Zimbabwe 159, 160–161, 172 preventing mother-to-child transmission 160, 165 prevention 158, 161, 166–167, 170, 172, 172–173, 196–197 Russia 261, 327 South Africa 15, 161–167, 170, 197–198, 313, 315, 320, 324, 324 southern Africa 155–175, 310, 312, 313, 319, 324–323, 325 sub-Saharan Africa 155, 156–157 traditional medicine 315 transmission 28, 131, 161, 162, 165, 173, 312 United States 198, 261, 297, 303 vaccine 309, 321, 323 women 156, 157, 158, 159, 160–161, 162, 163, 167, 171, 196 World Bank 337
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Innovation in Global Health Governance
HIV/AIDS Act (Zambia) 158, 170, 339 Hobbes, Thomas 143 Hogan, Barbara 170, 172 Hokkaido Toyako Summit 172 Hong Kong 83, 84, 87, 102, 124, 138, 161, 310, 311, 314, 316, 317, 323, 326, 327, 333 avian influenza 56, 83, 87, 89–90, 91, 107 Baptist Hospital 89–90 Canada 92, 98 China 90 Department of Health 89–90, 95 gross domestic product 30–31 Hospital Authority 89 influenza 83, 90, 92 Prince of Wales Hospital 89–90 secretary of health 89 severe acute respiratory synrome 27, 31, 32, 38, 40, 50, 63, 83, 84, 86, 87, 88, 90, 91, 92, 92–93, 94–104, 95, 101 economic impact 29–31 response 85, 93, 102 World Health Organization 31, 40, 91 Horn of Africa 214 Hospital Authority (Hong Kong) 89, 90, 95 hospitals 12, 35, 36, 37, 42, 52–53, 89–90, 93, 96, 98, 99, 110, 113, 159, 163, 164, 174, 298, 314, 326 HPAI. See avian influenza: highly pathogenic Huang, Yanzhong 32, 33, 310, 311, 313, 316, 317, 322, 327 Hu Jintao 87, 90 Human Development Index 161 Human Development Report 121 human health 10, 108, 110, 112, 130, 185, 257, 279, 281 human rights 5, 14, 15, 15–16, 16, 106, 118, 119, 121, 174, 179, 181, 184, 185, 193–203, 247, 296, 330, 340 human rights law 15, 197, 200, 202 human security 25, 84, 85, 91, 121–122, 129, 169, 326, 330, 340 Hundred Years War 144 Hungary 73, 227 hunger. See famine Hunter, Mark 162 hybrid viruses 130 hypertension 195
IAVI. See International AIDS Vaccine Initiative immunisation 16, 58, 213, 266, 278–281, 311. See also vaccination Inca 144 India 28, 61, 86, 138, 146, 183, 186, 194, 214, 217, 251, 302, 311, 313, 321, 333 Indian Ocean 288 Indonesia 83, 86, 87, 88, 114, 133, 145, 316, 324, 330 gross domestic product 138 infectious disease 3, 4, 11, 13, 14, 17, 23, 40, 58, 64, 84–85, 91, 92, 94, 95, 106, 107, 113, 114, 119, 129, 133, 147, 254, 261, 281, 285, 286, 287, 289, 293, 294, 295, 296, 297, 298, 299, 300, 315 Asia 83, 85–92 China 87 developing countries 26–27, 290–291 economy 135 eradication 287, 291 global health initiatives 291 outbreak 84 respiratory 83, 84 securitisation 120 security 25 transmission 83–84, 87, 94, 95, 99, 102, 115–116, 312–313 United States 25 influenza. See also influenza pandemic; pandemic influenza 1918 Spanish 14, 28, 60, 83, 106, 129, 130–131, 134, 139, 141–142, 143, 144, 146, 148, 311, 313, 325, 326, 333 comparison with H5N1 131, 143, 144 case fatality rate 148 comparison with H5N1 136 military impact 143 1957 130 1968 130 avian-to-human transfer 130–131 H1N1 117, 333 Hong Kong 83 outbreak 92–93 prevention 93 United States 129
Index influenza pandemic 3, 13, 14, 83–84, 92–103, 115, 119, 129–149, 291, 310, 325. See also influenza; pandemic influenza impact economic impact 135, 138 sociopolitical 139–143 outbreak 139 security 129–130 war 132 Institute of Medicine of the National Academies 130 Institute of Social and Ethical Accountability 228 Integrated Framework and Aid for Trade Initiative 254 intellectual property 116, 182, 183, 185, 187, 196, 197, 247, 248–249, 251 intellectual property law 15, 180 intellectual property rights 116, 185, 186, 189, 198, 247, 258 Inter-American Development Bank 213 intergovernmental negotiating body 219, 223, 224–223, 225, 234 Intergovernmental Working Group on Public Health, Innovation, and Intellectual Property 17, 245, 247–248, 337 International AIDS Conference 164 International AIDS Vaccine Initiative 286, 288, 292, 296, 321, 334, 338 International Campaign to Ban Landmines 17, 288 International Conference on Financing for Development 293 International Conference on Health Promotion 49–50 International Court of Justice 69, 77 International Covenant on Economic, Social, and Cultural Rights 15, 179–180, 184, 201 International Development Association 336 International Federation of Red Cross 123 International Health Regulations 5, 12, 13, 39–40, 40, 56, 67, 71, 72, 76, 133, 236, 246, 247, 248, 249, 316, 323, 329, 330, 336, 337 international institutions 246, 257, 264, 265, 277, 290, 301, 314, 319, 328, 329–330, 332
391
International Labour Organization 110, 158, 334 International Ministerial Conference on Avian and Pandemic Influenza 112 International Monetary Fund 5, 110, 222, 334 international organisations 5, 16, 17, 31, 40, 41, 44, 60–61, 63–77, 193, 195, 197, 198, 211, 251, 254, 257, 258, 259, 262, 264, 279, 281, 302, 314, 319, 329 authority 63, 66, 70–71, 75, 76 constitution 68–69 global health initiatives 288 mandate 65, 77 International Policy Statement (Canada) 298–299, 339 International Sanitary Rules 40 International Tobacco Growers Association 221 International Tobacco Products Marketing Standards 226, 229, 339 International Trade in Health Services and the GATS: Current Issues and Debates 254 internet 29, 32, 37, 56, 60, 98, 133, 314, 315, 320, 322, 329 investment 24, 134, 137, 139, 180, 196 IPV. See polio: inactivated polio vaccine Ireland 86, 234 Italy 86, 117, 124, 140, 234, 260, 319 Jacob, Gregory F. 231–232, 233 Jakujyan, Taleen 266, 273 Jamaica 73 Japan 26, 30, 73, 83, 107, 113, 117, 124, 129, 194, 221, 224, 230, 260, 261, 271, 319 Japan Tobacco/R.J. Reynolds 226, 227, 231 Jervis, Robert 27 Jews 140, 313 Jiang Yanyong 32 Joint United Nations Programme on HIV/ AIDS. See UNAIDS Jolie, Angelina 286 Jubilee Debt Campaign 17, 288 Juricevic, Diana 266 Jurong Police Station 101 Kamradt-Scott, Adam 312, 315–314, 315, 321, 322, 323, 324, 327, 328
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Innovation in Global Health Governance
Kananaskis Summit 258 Kaul, Inge 302 Keachie, Heather 266, 273 Kean, Bill 75 Khomanani 167 Khoubessarian, Caroline 310, 317, 319, 321–320, 322 Kickbusch, Ilona 246 Kirton, John 200, 202, 266, 317 KMT 91 Kobe declaration 221 Kokotsis, Ella 266 Korea 73, 83, 86, 91, 107, 113, 195 Kowloon 89 KPMG 33 Krasner, Stephen 27 Kuala Lumpur 38 Kuchenbecker, Ricardo 123–124 Kuek, Vicky 189 Kukowara, Greg 189 Kunz, Catherine 273, 317 Kuwait 86 La Becque 144 Labonté, Ronald 258 labour 56, 136, 137, 139, 141, 158, 161, 166, 232, 302, 325 Lalonde, Marc 49 Laos 113 Latin America 156, 194, 201, 211, 213, 214 law 66, 67, 220, 231, 246, 320, 329, 336. See also human rights law; intellectual property law; patent law; trade law Learning from SARS 102 least developed countries 43, 182, 184, 186, 188, 195 Leavitt, Michael 57 Lee, Kelley 314, 316, 318, 319, 328 Lee Kuan Yew 133 Leftwich, Adrian 303 Legality of the Use by a State of Nuclear Weapons in Armed Conflict 69 Le Gaulvain, Katell 302–303 Legionnaires’ disease 99, 289, 333 legislation 86 legitimacy 141, 142, 146, 328, 330 Lehohla, Pali 163 leishmaniasis 183
Lesotho 155, 156, 168 leukemia 195 Lewis, Maureen 135 Lewis, Stephen 164, 258 life expectancy 4, 163, 325 Limpopo Province 165 Li Quan 266 Liu Jianlun 31 Lo, Sonny Shiu-Hing 315, 319, 323 lobbying. See advocacy low-pathogenic avian influenza (LPAI). See avian influenza: low-pathogenic avian influenza Macao 83, 84, 86, 90, 92, 333 Macroeconomics and Health: Investing in Health for Economic Development 290 Mahidol University 57 malaria 4, 31, 40, 42, 43, 57, 114, 119, 160, 172, 183, 194, 196, 220, 259, 262, 263, 278–281, 286, 289, 296, 312, 319, 330, 333 Malawi 155, 168 Malaysia 38, 85, 86, 138, 236 Maldives 73 Mandela, Nelson 166, 198, 339 Mannell, Jenevieve 266, 273 Martin, Paul 58 maternal health 196, 295 Mattoo, Aaditya 254 Ma Ying-jeou 91 Mbeki, Thabo 41, 163–164, 165, 169, 170, 172 McClellan, Anne 34 McLeod, A. 123 McLuhan, Marshall 52 McNeill, William 25 measles 117, 212, 333 meat 116 Médecins Sans Frontières 182, 198, 314 media 36, 59, 87, 90, 92–94, 100, 133, 286–287, 292, 314, 319, 320, 321, 328–329. See also communcations medical officers of health 34, 54, 59, 60, 339 medicare 50 medicines. See drugs Mencken, H.L. 51 Meng Xuenong 32
Index Mexico 55, 61, 124, 235, 266, 321 Middle East 156, 194 migration 4, 15, 23, 24, 43, 96, 99, 107, 119, 120, 133, 162, 173, 247, 297, 302, 321, 324, 325. See also brain drain military 25, 31, 110, 121, 129, 143–146 Millennium Declaration 291 Millennium Development Goals 106, 113, 118, 122, 124, 132, 196, 245, 291, 292, 295, 299, 315, 340 Millions Saved Project 303 Ming Pao 102 Moldova 227 money mobilised 318, 318–319, 322, 323, 329, 336. See also G8: money mobilised Mongol 145 Mongolia 73, 86 Montreal 55, 100 Morgan Stanley 30 Morocco 212 mortality 28, 31, 116, 136, 196. See also deaths avian influenza 117 communicable disease 194 HIV/AIDS 15, 131, 159, 163, 165, 194 influenza 40, 44, 59, 105, 138, 139, 145, 148 malaria 194 severe acute respiratory syndrome 24, 28, 108 tuberculosis 194 Motlanthe, Kgalema 166 Movement for Democratic Change 41 Mozambique 155, 168 MTV 286 Mugabe, Robert 41, 159, 160 Multi-Country HIV/AIDS Program for Africa 158, 169–170, 199, 337 multinational corporations 139, 229 Muslims 145 Myanmar 201 Nakajima, Hiroshi 220, 221 Namibia 155, 156, 168 Napoleon Bonaparte 146 National Advisory Committee on SARS and Public Health 34, 53, 57, 59, 84, 85, 102, 103, 339
393
National AIDS Coordinating Agency (Botswana) 157 National AIDS Coordination Programme (Zimbabwe) 159, 339 National AIDS Council Botswana 157, 170, 339 Zambia 170 Zimbabwe 159, 170 National AIDS Policy (Zimbabwe) 160 National AIDS Trust Fund (Zimbabwe) 160 National Behaviour Change Strategy (Zimbabwe) 159 National Emergency Response Council on HIV/AIDS (Swaziland) 157, 339 National Emergency Response System (Canada) 93 National HIV/AIDS/STD/TB Council (Zambia) 158, 339 National HIV/AIDS Framework (Zimbabwe) 160 National HIV Estimates Process (Zimbabwe) 175 national immunisation days 213, 214 National Institute of Aging (United States) 139 National Institutes of Health (United States} 139 national manufacturers associations 227 National Microbiology Laboratory 60 National Strategic Plan on HIV/AIDS (Botswana) 157 natural disaster 4, 120, 132 Naylor, David 50, 52, 54 neglected diseases 5, 183 neo-liberalism 5, 230, 258, 259, 290, 316, 317 Nepal 214 Netherlands 117, 198, 234 nevirapine 165, 167 new chemical entities 183 New Delhi 112 A New Perspective on the Health of Canadians: A Working Document 49 New York 216 New Zealand 86 Ng, Emily 189 Nigeria 214, 217, 311, 313, 315, 316 Nigerian Ogoni 228
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Innovation in Global Health Governance
Nolen, Stephanie 303 non-communicable disease 10, 183, 194, 298, 318, 332, 333 non-state actors 8, 9, 40, 41, 311, 318, 329, 332, 337 nongovernmental organisations 3, 12, 23, 31, 40, 42, 43, 56, 57, 61, 85, 106, 111, 121, 122, 133, 147, 159, 160, 163, 166, 169, 170, 172, 173, 201, 211, 216, 217, 224, 245, 259, 301, 314, 332. See also civil society North 4, 10, 11, 8, 145, 294, 295, 301, 310, 312, 317, 325, 329, 332 North Africa 156 North America 114, 156, 194, 196, 211, 213, 312, 326–327, 327, 333 North American Free Trade Agreement 117 Northern Ireland 235 Norvasc 195 Norway 220 Nugent, R. 123 Nunavut 100 nutrition 60, 109, 186, 295, 328 obesity 4, 312, 328, 333 official development assistance 17–18, 285–287, 289, 290, 292, 293, 295, 295–296, 298, 299–300, 301, 302, 315, 316, 322, 324. See also aid OIE. See World Organisation for Animal Health Okinawa Summit 259, 319 Oldani, Chiara 259 O’Manique, Colleen 200 Ontario 33, 34, 37, 52, 53, 92, 99, 100, 103 finance minister 33 health minister 33, 54 Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South Africa 166–167 Operation Mop Up 214–215 Opukah, Shabanji 228 OPV. See polio: oral polio vaccine Orbinski, James 203 Organisation for Economic Co-operation and Development 138, 215, 326 Organisation of the Islamic Conference 215 Ottawa 34, 55, 85, 100
Ottawa Charter for Health Promotion 49 Otte, M. 123 outbreak 10, 26, 30, 56, 59, 64, 72, 88, 88–89, 95, 133, 133–134, 281, 287, 310, 313, 323 Outreach Five 61, 321, 328 Pacific Rim 24, 41, 322. See also Asia Pacific region severe acute respiratory syndrome 24, 26, 28, 31, 42 Pakistan 73, 214, 217 Pan American Health Organization 213, 335 pandemic 43, 55, 63, 83, 106, 113, 130, 136, 248 economic impact 97, 83–84, 130–131, 325 pandemic influenza 43, 55, 57, 59, 120, 130–149. See also influenza; influenza pandemic case fatality rate 135 deaths 135, 136 Pandemic Influenza Plan for the Health Sector (Canada) 13 Panel of Eminent Persons on United Nations–Civil Society Relations 106 Paris 55 patent 180, 182, 183, 185–186, 187–188, 194–195, 195, 197, 201, 248, 340 patent law 185, 186, 189, 249 patent rights 182 pathogens 310 Payne, Anthony 303 peace 106, 340 Peel Region 99 Peloponnesian War 144 people with disabilities 60 PEPFAR 124, 158, 172, 175, 199, 297, 303, 339 Perez Cosio, Andrea 189 pertussis 212, 333 Peru 214 Peterson, Susan 12, 64, 65–66, 67, 68, 76, 77 pets 97 Pettiford, Lloyd 303 Pfizer 195 pharmaceutical industry 3, 5, 15, 16, 58, 117, 124, 164, 169, 170, 179–190, 193, 196, 197–198, 198, 258, 318
Index Pharmaceutical Manufacturers’ Association of South Africa 197–198, 199 pharmaceutical research and development 180, 182, 183. See also research and development pharmaceuticals. See drugs philanthropy 6, 314, 329. See also foundations Philip Morris International 224, 226–228, 235 Philippines 85, 86, 138, 195, 212 pigs 55, 91, 107, 115, 117, 123, 311 plague 3, 23, 30, 40, 70, 313, 328. See also bubonic plague plague of Athens 24, 140, 144, 313, 326, 333 plague of Justinian 145, 333 plague of Surat 28, 140, 313, 325, 333 plant health 110, 185 pneumonia 35 Poland 227 polio 10, 211–217, 286, 310, 310–311, 312, 313, 315, 318, 321, 324, 325, 329, 333, 340 eradication 16, 266, 289, 310–311, 311, 314, 316 G8 262, 278–281 money mobilised 318–319 prevalence 211, 216, 311 source 10 vaccine 117, 309, 312, 315, 336 wild polio virus 216 Polio Advocacy Group 215, 334, 338 PolioPlus 16, 211, 212, 215, 217, 286, 288, 334, 338 population growth 107, 139, 161 population health 14, 17, 49, 134, 134–135, 169, 246, 250, 251, 252, 302, 324, 340 poultry 84, 97, 107–109, 111 slaughter 87, 91, 107–108, 124, 316 poultry industry 112, 113–114, 115, 117, 123 poverty 4, 5, 49, 106, 107, 121, 132, 161–162, 165, 183, 290 Prague 55 preparedness 13, 14, 54, 55, 56, 57, 58, 59, 85, 92, 92–96, 106, 109–110, 118–119, 120, 132, 132–133, 143, 146–147, 315, 317, 319. See also crisis response
395
Prescott, Elizabeth 25, 34 Preserve Planet Earth 216 prevention 17, 38, 49 Price-Smith, Andrew 41, 258, 310, 311, 316, 317, 322, 327 Prince of Wales Hospital (Hong Kong) 89–90, 95 private sector 6, 7, 8, 15, 100, 105, 111, 112, 114, 121, 123, 160, 169, 232, 250, 259, 291, 301, 314, 318, 320, 321, 339 Prosperity: Aligning Diplomacy and Development Assistance 339 protease inhibitors 196 public-private partnership 5, 6, 89, 90, 100, 111, 288 Public Health Agency of Canada 12, 34, 51, 54, 59, 339 public health infrastructure 43, 50 punctuated equilibrium 26–28, 31, 34, 44, 327 quarantine 28, 29, 68, 89, 90, 94, 97–98, 98, 99, 101, 108, 110, 119, 120, 131, 145, 315, 316, 317, 325, 326 economic impact 137–138 severe acute respiratory syndrome 30, 34 Quarantine Act (Canada) 55, 59 Quebec 52, 93, 100 R.J. Reynolds 226. See also Japan Tobacco/ R.J. Reynolds racism 119, 140, 258. See also discrimination reassortment 130 regulation 3, 5, 49, 58, 69, 97, 101, 112, 116, 183–184, 246, 249, 256, 314, 316, 317 Regulations on Public Health Emergencies 37 Report of the High Commissioner for the Commission on Human Rights 185 research and development 5, 49, 58, 124, 182, 183, 184, 198, 247, 248, 296, 302, 318, 324. See also pharmaceutical research and development respiratory disease 28 rights 94, 95. See also animal rights; human rights; intellectual property rights; patent rights
396
Innovation in Global Health Governance
right to health 5, 15–16, 180, 184, 246, 258, 319, 320, 321, 322, 324, 330, 340 right to medicine 180 The Right to the Highest Attainable Standard of Health 337 Rio Tinto 228 Riyadh 224 Roach, Stephan 30 Rockefeller Foundation 3, 212, 314, 318 Rodrik, Dani 181, 182 Roemer, Ruth 220, 221, 318 Roll Back Malaria 287, 334, 338 Roman Empire 146 Romania 86, 234 Roosevelt, Franklin D. 212 Rotary Foundation 215, 216 Rotary Health, Hunger, and Humanity Program 212 Rotary International 16, 211–217, 286, 288, 314, 316, 318, 325, 329 Roudev, Nikolai 317 Ruger, Jennifer Prah 232 Russia 86, 107, 108, 226, 261, 265, 319, 327 Rwanda 200 Sabin, Albert 213 Sachs, Jeffrey 286, 289 Salk, Jonas 213 San Francisco 77 sanitation 3, 109, 113, 115, 118 SARS. See severe acute respiratory syndrome SARS, Governance, and the Globalization of Disease 64 SARS Control and Prevention Headquarters of the State Council 36 Saudi Arabia 224 Saul, John Ralston 180 Save the Children 57 Savona, Paolo 259 Schelling, Thomas 146 Schnupf, Mirjam 302 Schönteich, Martin 169 Schrecker, Ted 200, 202 Schumpeter, Joseph 26 science 8, 52, 63, 211, 321 Scotland 234 Scruton, Roger 231
Secretariat for Public Health, Innovation, and Intellectual Property 247–248 securitisation 106, 120 security 4, 5, 9, 25, 36, 43, 83, 85, 95, 101, 105, 118, 120, 121, 129–149, 146, 169, 247, 290, 296, 297, 299, 300, 314, 320, 323, 324, 328, 340. See also health security; human security Security and Prosperity Partnership of North America 319 Sen, Amartya 233 September 11, 2001 25, 50, 113, 120, 129, 169, 291, 324 Seven Oaks Home for the Aged (Toronto) 99 severe acute respiratory syndrome 10, 11–13, 14, 23, 23–44, 44, 49, 50, 63–77, 83, 83–103, 109, 119, 120, 131, 139, 146, 286, 309, 315, 317, 319, 322, 325, 326, 327, 328, 329, 333, 340 as outbreak epidemic 30 ASEAN 37–39, 321, 328, 337 Canada 12, 13, 24, 26, 27, 312, 314, 317, 322, 323, 327 case fatality ratio 85 China 12, 13, 24, 26, 29, 32, 35–37, 83, 84, 111, 142, 312, 314, 315, 317, 320, 322, 323, 328, 329, 340 deaths 10, 24, 28 declaration of containment 32, 64, 76 eradication 66, 69, 75 G8 262, 273–274, 275, 281 health workforce 29, 53, 67, 90–91, 310 history 31–32 Hong Kong 27, 29, 83, 84, 88, 92–93, 93 impact economic 11–12, 29–30, 32–33, 52, 63, 76, 94, 135, 136, 137, 138, 139, 325 sociopolitical 139–140 political security 325–326 index case 31, 89–90 North America 312, 326–327 outbreak 63, 310, 323 Pacific Rim 28, 322 preparedness 85, 323 prevalence 31, 310 quarantine 29, 30, 34, 98, 316
Index response 32, 34, 35, 133, 315, 327 Singapore 94 source 10, 35, 85, 311 Taiwan 27, 83, 321 traditional medicine 29 transmission 24, 28, 28–29, 31, 41, 42, 52, 53, 55, 63, 108, 131, 310, 312 transparency 38–39, 43 World Health Organization 32, 34, 52, 72, 111, 315–314, 317, 320, 321, 322, 324, 325, 327, 329, 330 global alerts 31, 40, 123 response 63–77 travel advisory 34, 38, 40–41, 52, 316, 329 Shaanxi 29 Shalden, Ken 183–184 Shell Oil 228 Shelton, Dinah 200 Shi Huangdi 49, 50, 57, 61 Siberia 84, 107 Sierra Leone 212 Silberschmidt, Gaudenz 246 Singapore 12, 31, 37–38, 39, 53, 54, 73, 83, 84, 85, 86, 87, 89–90, 90, 91–92, 94–96, 98–99, 101, 102, 133, 138, 314, 319, 323, 326 health minister 53 Slaughter, Anne-Marie 301 Slinger, Abby 266, 273 smallpox 3, 4, 7, 23, 247, 286, 289, 309, 312, 315, 333 Smallpox Eradication Programme 288 Smallpox initiative 334, 338 Smith, Richard 254, 302 smoking 4, 219, 226, 229, 234, 311, 312, 328 social cohesion 119, 141, 142, 161, 325 Social Development Priorities Strategy 298 social movements 106, 193, 200, 201, 202–203 Somalia 201 Sorbara, Gregory 33 South 5, 8, 10, 11, 119, 145, 200, 285, 294, 296, 298, 301, 310, 312, 325, 329, 332 South Africa 43, 61, 86, 165, 339 access to medicine 197–198, 201 Department of Health 165
397
HIV/AIDS 15, 16, 155, 161–167, 168, 169, 170, 171, 172, 174, 197–198, 313, 315, 320, 324 human rights 16, 201–200 southeast Asia 12, 25, 39, 42, 56, 57, 108, 113–114, 115–116, 117, 118, 143, 194, 224, 225, 311, 329 southern Africa 15, 155–175, 325 HIV/AIDS 310, 312, 313, 319–318, 324–323, 325, 325–326 sovereignty 5, 6, 8, 9, 10, 23, 25, 26, 31, 33, 40, 41, 42, 43, 65, 72, 120, 132, 259, 301, 314, 315, 316, 328–330, 330, 332 Soviet Union 4 Soweto 165 Spain 86, 161, 234 Spanish influenza. See influenza: 1918 Spanish Speaker, Andrew 55 Special 301 Report 186, 189, 196 Spectrum 159 SPS Agreement. See Agreement on the Application of Sanitary and Phytosanitary Measures St. Petersburg Summit 257, 265, 319 Statistics South Africa 163 Stephens, Gina 266 Stern, Robert M. 254 Stiglitz, Joseph 179 stockpiling 55, 84, 99, 103, 117–118, 316 Stop TB Partnership 285, 286, 287, 334, 338 structural adjustment programmes 290 sub-Saharan Africa 41, 143, 155, 156, 168, 194, 196–197, 197, 199 Sudan 333 Sunderland, Laura 273, 317, 322 Sunter, Clem 161 Surat. See plague of Surat surveillance 28, 31, 37, 42, 43, 44, 50, 57, 58, 59, 84, 86, 87, 89, 90, 92, 93, 94, 101, 109, 111, 122, 133, 147, 148, 159, 213, 314, 315, 316, 322, 329 Sustainable Development Strategy 298–299 Swaziland 15, 155, 156, 156–157, 168, 169, 325, 339 Ministry of Health 156, 157 Sweden 73, 86, 234 swine. See pigs
398
Innovation in Global Health Governance
swine influenza 147, 310, 333 swine vesicular disease 36 Switzerland 86 Taiwan 5, 27, 31, 83, 84, 85, 86, 89–90, 90–91, 91, 92, 96, 102, 310, 321 Takacs, Danielle 266, 273 Tamiflu 98, 102, 103, 132 Taylor, Allyn 220, 221, 318 TBT Agreement. See Agreement on Technical Barriers to Trade temperature testing 90, 96, 100, 101, 315, 316 terrorism 23, 55, 95, 145. See also bioterrorism tetanus 212, 333 Thailand 12, 38, 57, 58, 73, 83, 84, 85, 86, 87–88, 88, 99, 107, 113, 123, 138, 189, 195, 196, 201, 202, 224, 225, 235, 251, 310, 319, 327–328 Thaksin Shinawatra 38 Therapeutic Solidarity Initiative 334, 338 Thomas, Nicholas 25 Thucydides 24–25, 140, 313 Tiananmen Square 120, 142 Tianjin 140 Tibet 107 Time Magazine 286 tobacco-related diseases 311, 312 Tobacco and the Rights of the Child 221, 337 tobacco control 219–237, 247, 251, 314, 314–315, 317, 318, 319, 322, 329, 333, 337 corporate social responsibility 228–229 foreign policy 229–234 Tobacco Free Initiative 220, 226, 228, 231 tobacco industry 16, 219, 220, 222, 224, 225, 225–229, 233, 235 tobacco use 10, 310, 312, 325 Toronto 13, 33, 34, 40, 50, 52, 54, 84, 98, 99, 100, 102, 119, 164, 316, 317, 325, 326 tourism 23, 24, 29, 29–30, 30, 33, 34, 38, 40, 44, 52, 91, 102, 325 trade 14, 15, 17, 23, 24, 25, 28, 30, 40, 43, 44, 55, 91, 109, 110, 116, 116–118, 119, 120, 121, 137, 139, 145, 147–148, 179, 181, 184, 185, 186, 187, 189, 197, 202,
220, 221, 224, 226, 230, 245–252, 254, 256, 291, 293, 314, 319, 320, 322, 325, 340 health services 247, 249, 251, 256 trade agreements 196, 249, 254, 256 trade and health diagnostic tool 254, 336 trade law 188, 258 trade liberalisation 230, 235, 250, 252, 255, 324 trade ministers 246, 249, 250, 251, 252 trade unions 94, 95, 106, 119 traditional medicine 29, 164, 167, 169, 171, 172, 315, 324 transparency 12, 13, 17, 36, 38–39, 40, 41, 43, 50, 56, 58, 59, 61, 87, 88–89, 93, 109, 111, 114, 119, 122, 147, 225, 251, 252, 322, 340 transport 4, 29, 55, 93, 98, 124 travel 29, 38, 55, 63, 67, 83, 87, 98, 100, 109, 119, 120, 124, 133–134, 134, 135, 137, 147–148, 310, 312, 313, 316 Treatment Action Campaign (South Africa) 164 TRIPS Agreement. See Agreement on Trade-Related Aspects of Intellectual Property Rights tropical diseases 182, 318 trypanosomiasis 5 Tsang, Thomas 32 Tshabalala-Msimang, Manto 164, 166, 172 tsunami 109, 112, 288 tuberculosis 4, 31, 40, 42, 55, 87, 114, 167, 172, 194, 212, 259, 262, 263, 266, 278–281, 281, 286, 289, 312, 333 Tung, C.H. 96 Turkey 73, 117 turkeys 84, 108 typhoid 119, 333 ubuntu 201 Uganda 174 UK International Priorities: A Strategy for the FCO 339 Ukraine 123, 227 Ullman, Richard 129, 148 UNAIDS 57, 172, 173, 196, 301, 334, 337 337 UNCTAD 220, 221, 334
Index unemployment 162, 165 UNICEF 212, 213, 215, 221, 334, 337 United Kingdom 26, 55, 73, 84, 86, 117, 261, 271, 296, 300, 317, 333, 339 Department for International Development 295, 296, 296–297, 299 National Health Service 296 official development assistance 285, 295 tobacco control 235–234 United Nations 7, 44, 77, 106, 109, 122, 160, 198, 211, 233, 257–258, 261, 291, 293, 301, 302, 314, 320, 321, 329, 334, 337 G8 258, 259–260 General Assembly 276, 336 Rotary Foundation 216–218 Rotary International 16 secretary general 123 Security Council 25, 290, 334, 337 tobacco control 221, 222, 234 World Health Organization 302 United Nations Association in Canada 105, 106, 123 United Nations Conference on Trade and Development. See UNCTAD United Nations Declaration of Human Rights 185 United Nations Development Programme 57, 110 United Nations Economic and Social Council 184, 337 Commission on Human Rights 185 Committee on Economic, Social, and Cultural Rights 185 United Nations Environment Programme 110, 334 United Nations Foundation 215 United Nations High-Level Panel Report 132 United Nations International Children’s Fund. See UNICEF United Nations Special Envoy for HIV/ AIDS in Africa 164 United Nations World Summit 199, 302, 334, 337 United States 26, 42, 43–44, 53, 55, 98, 113, 115, 129, 134, 135, 144, 146, 200, 201, 213, 258, 260, 300, 317, 326, 333, 339
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1918 Spanish influenza 83, 129, 138, 141–142, 142 access to medicine 198, 319 anthrax 311, 324, 333 avian influenza 103, 117 Congress 124 Department of Health and Human Services 55, 59, 135 Department of Justice Office of Legal Counsel 231 drugs 195–196 G8 261, 271, 330 H5N1 130 HIV/AIDS 172, 198, 261, 297, 319 influenza 129 economic impact 325, 138 sociopolitical impact 141–142 official development assistance 286, 295–306 preparedness 132–133 Rotary International 216–218 secretary of health and human resources 57 Senate Committee on Foreign Relations 144 severe acute respiratory syndrome 86, 94, 140 prevalence 31, 310 State Department 297 tobacco control 220, 224, 225, 230, 231–232, 233, 235, 319 trade 116–118 World War I 131–132 United States Agency for International Development. See USAID United States Central Intelligence Agency 291 United States Homeland Security Council 136 United States National Intelligence Council 25, 129, 303 United States National Intelligence Estimate 25 United States President’s Emergency Plan for AIDS Relief. See PEPFAR United States Trade Act 189 United States Trade Representative 186, 188, 189, 196
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Innovation in Global Health Governance
Universities Allied for Essential Medicines 183 University of Hong Kong 29, 148 University of Western Ontario 102 Uruguay Round 182, 276 USAID 158, 170, 213, 295, 297–298 Utah 57 Uzbekistan 227 vaccination 99, 112, 330. See also immunisation vaccine 6, 58, 89, 93, 95, 102, 110, 113, 114, 116, 117, 122, 124, 132, 145, 147, 312, 313, 316 avian influenza 117–118, 124, 309, 321 H5N1 55 HIV/AIDS 309, 321, 323 inactivated polio vaccine 213 influenza 55, 98, 99, 102, 132, 133 oral polio vaccine 213 polio 16, 211, 212, 213, 309, 315 swine influenza 124 Vancouver 55, 84, 99, 100 Varmus, Harold 303 Venice 146 Vétérinaires Sans Frontières 57 veterinary epidemics 36 veterinary services 60, 108, 117, 121 Vienna Convention on the Law of Treaties 186 Vietnam 31, 32, 42, 56, 57, 71, 73, 85, 86, 91, 107, 113, 123, 124, 133, 148, 310, 316, 326, 327–328 von Furstenberg, George 266 Wales 235 Walkerton 37, 50 war 4, 9, 23, 44, 95, 107, 131–132, 155, 320, 340 water 3, 50, 109, 118, 120, 281 Waterloo, Ontario 103 Waxman, Henry 224 Weekly Epidemiological Record 70 Wen Jiabao 36, 36–37, 38, 90 West Africa 214 Western Cape Province 165 West Nile virus 23, 44, 99, 291, 310, 333
Westphalian principles 8, 9, 18, 40, 64, 259, 309, 326, 328 White, Kathryn 314, 317, 322 Whiteside, Alan 161 Wilson, Woodrow 144 Winnipeg 55, 56, 60, 216 Wolfensohn, James 223 women 160, 170, 200 Woodward, David 302 World AIDS Day 166 World Bank 5, 51, 57, 61, 110, 135, 158, 169, 173, 199, 216, 219, 233, 254, 290, 301, 303, 315, 317, 320, 334, 337, 340. See also Multi-Country HIV/AIDS Program for Africa tobacco control 221, 222–223, 230, 231, 236 World Conference on Tobacco or Health 220 World Development Report 222, 337 World Food Programme 110, 334 World Health Assembly 40, 67, 68, 73, 76, 133, 214, 247, 248, 325 Framework Convention on Tobacco Control 219 tobacco control 220, 223–224 WHA48.7 Revision and Updating of the International Health Regulations 67 WHA48.13 Diseases Prevention and Control: New, Emerging, and Reemerging Infectious Diseases 67 WHA52.18 Towards a WHO Framework Convention on Tobacco Control 223–224 WHA54.14 Global Health Security: Epidemic Alert and Response 13, 72 WHA56.27 Intellectual Property Rights, Innovation and Public Health 247 World Health Organization 3, 4, 6, 17, 41, 43, 55, 56, 60, 64–65, 68, 70, 71–72, 90–91, 91, 102, 109, 110, 123, 124, 130, 132, 173, 189, 194, 212, 233, 245, 259, 261, 264, 298, 301, 302, 317, 320, 329, 330, 334, 337, 340 ‘3 by 5’ initiative 199, 286, 287, 292, 298, 325, 334, 338 agency slack 64, 77, 317 antiretroviral treatment 165, 199, 336
Index authority 12–13, 64, 66, 68, 71, 72, 73–74, 74, 76 avian influenza 57, 84, 124 Canada 59, 73, 123, 330 China 13, 31, 32, 72, 76, 77, 87, 91, 320, 329, 330 constitution 13, 68–70, 72, 73 crisis response 14, 55, 68, 324 diagnostic tool for trade and health 251, 256 G8 257, 258, 260, 262–263, 265, 277, 321 global alerts 31, 40, 67, 67, 70, 72, 75, 123, 133, 337 global health initiatives 17, 302 H5N1 42, 84 health diplomacy 247, 249 health governance 5, 12–13, 17, 233 health ministers 60 HIV/AIDS 196–197, 263, 290 Intergovernmental Working Group on Public Health, Innovation, and Intellectual Property 247–248 International Health Regulations. See International Health Regulations mandate 12–13, 61, 64, 71, 73 polio 214–218 severe acute respiratory syndrome 12, 12–13, 34, 63, 72, 111–112, 148, 315–314, 317, 320, 321, 322, 327, 329, 330 declaration of containment 32, 64, 76, 325 response 63–77, 133 travel advisory 71–72, 316, 321 tobacco control 219–227, 230, 231–232, 234, 246, 247, 315–314, 329–330 trade 249, 250–251, 254 travel advisories 34, 40, 52, 66, 67, 70–71, 72, 75, 87, 316, 317, 321, 329 World Trade Organization 249, 251, 252, 254, 338 World Organisation for Animal Health 58, 110, 123, 322, 334
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World Tourism Organization 75 World Trade Organization 16, 75, 110, 116, 180, 187, 188, 189, 195, 198, 222, 249, 250, 251, 252, 320, 324, 334, 337 beef 116–118 Declaration on the TRIPS Agreement and Public Health. See Declaration on the TRIPS Agreement and Public Health World Health Organization 249, 251, 252, 254, 338 World War I 3, 131–132, 142, 144, 148 World War II 3, 44 Wu Yi 36 Xinhua 36 Y2K 56–57 Yach, Derek 220, 237 yellow fever 40, 146, 286, 333 Yeoh Eng-kiong 89 York Region 99 Zaire 333 Zambia 15, 73, 155, 158, 164, 168, 169, 339 Zanini, Gianni 254 Zartman, William 27 Zhang Wenkang 32 Zhonghua Taiwan 91 Zhongnanhai 28 Zhongshan 102 Zhuhai 102 Zimbabwe 15, 41, 43, 73, 155, 159–161, 168, 168–170, 171, 172, 174, 175, 224, 226, 319, 324, 325, 339 HIV/AIDS 15, 319, 324–323, 325 Ministry of Health and Child Welfare 160 Zimbabwe National and HIV/AIDS Strategic Plan 160 Zimmerman, Brenda 51, 61
Global Environmental Governance Series Full series list
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