The Oxford Handbook of Global Health Politics 9780190456818, 0190456817

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T h e Ox f o r d H a n d b o o k o f

GL OBA L H E A LT H POL I T IC S

the oxford handbook of

GLOBAL HEALTH POLITICS Edited by

COLIN MC INNES, KELLEY LEE, and

JEREMY YOUDE

1

1 Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and certain other countries. Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America. © Oxford University Press 2020 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, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by licence, or under terms agreed with the appropriate reproduction rights organisation. Inquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above. You must not circulate this work in any other form and you must impose this same condition on any acquirer. Library of Congress Cataloging-in-Publication Data Names: McInnes, Colin, editor. | Lee, Kelley, 1962– editor. | Youde, Jeremy R., 1976– editor. Title: The Oxford handbook of global health politics / edited by Colin McInnes, Kelley Lee, and Jeremy Youde. Other titles: Handbook of global health politics Description: New York, NY : Oxford University Press, [2020] | Includes bibliographical references and index. Identifiers: LCCN 2019019778 | ISBN 9780190456818 (hardcover : alk. paper) Subjects: | MESH: Global Health | Health Policy | International Cooperation Classification: LCC RA441 | NLM WA 530.1 | DDC 362.1—dc23 LC record available at https://lccn.loc.gov/2019019778 1 3 5 7 9 8 6 4 2 Printed by Sheridan Books, Inc., United States of America.

Contents

About the Editorsix Contributorsxi Foreword, by Peter Piotxiii

1. Global Health Politics: An Introduction Colin McInnes, Kelley Lee, and Jeremy Youde

1

PA RT I   F ROM I N T E R NAT IONA L TO   G L OBA L   H E A LT H 2. The History of International Health: Medicine, Politics, and Two Socio-Medical Perspectives, 1851 to 2000 Marcos Cueto 3. Globalisation and the Politics of Global Health Matthew Sparke 4. The Politics of Global Health Inequalities: Approaches to Studying the Role of Power Yusra Ribhi Shawar and Jennifer Prah Ruger 5. Critical Approaches to Global Health Alan Ingram

19 37

59 85

PA RT I I   G L OBA L H E A LT H A N D T H E W I DE R   P OL IC Y AG E N DA 6. Global Health Diplomacy Akram Khazatzadeh-Mahani, Arne Ruckert, and Ronald Labonte´

103

7. Security and Health Simon Rushton

123

vi   contents

8. Global Health and Human Security Robert L. Ostergard Jr. and Jeffrey A. Griffin

143

9. Critical Security Studies and Global Health João Nunes

161

10. Biosecurity and the Risk to Global Health Christian Enemark

179

11. Military Assistance during Health Emergencies Adam Kamradt-Scott and Frank Smith

197

12. Global Health and International Development Andrew Harmer and Jonathan Kennedy

217

13. The Politics of Gender and Global Health Sarah Hawkes and Kent Buse

237

PA RT I I I   G L OBA L H E A LT H G OV E R NA N C E 14. Global Health Governance Colin McInnes

265

15. The State and Global Health Ted Schrecker

281

16. Emerging Powers and Global Health Governance: The Case of BRICS Countries Yanzhong Huang

301

17. The Politics of Global Health Agenda Setting Stephanie L. Smith and Jeremy Shiffman

325

18. The Politics of Intergovernmental Organizations in Global Health Tine Hanrieder

347

19. Civil Society and Global Health Politics David McCoy and Joseph Gafton

367

20. The Role of the Business Sector in Global Health Politics Kelley Lee and Julia Smith

387

contents   vii

21. Philanthropy and Global Health Jeremy Youde 22. Trade and Investment Agreements and the Global Politics of Health Chris Holden and Benjamin Hawkins

409

427

23. The Global Politics of Healthcare Reform Solomon Benatar, David Sanders, and Stephen Gill

445

24. Towards a Critical Political Economy of Global Health Ted Schrecker

469

PA RT I V   I S SU E S I N G L OBA L H E A LT H P OL I T IC S 25. The Human Right to Health and Global Health Politics Gorik Ooms and Rachel Hammonds 26. Reporting Disease Outbreaks in a World with No Digital Borders Sara E. Davies

493

513

27. The Politics of Pandemic Influenza Preparedness Adam Kamradt-Scott

531

28. The Global Politics of HIV and AIDS Alan Whiteside

551

29. The Global Politics of Neglected Tropical Diseases Obijiofor Aginam

569

30. The Politics of Global Vaccination Policies Stuart Blume

583

31. The Global Politics of Access to Medicines: From 1.0 to 2.0 Suerie Moon and Ellen ‘t Hoen

605

32. Non-Communicable Diseases and Global Health Politics Roger Magnusson

627

viii   contents

33. The Politics of Global Tobacco Control Kelley Lee

661

34. The Politics of Global Bioethical Frameworks Diego S. Silva and Jeremy Snyder

685

Index

699

About the Editors

Colin McInnes is professor of international politics in the Department of International Politics at Aberystwyth University, where he also obtained his PhD. He has been an academic consultant for the Nuffield Trust and World Health Organization and from 2007 to 2018 was the UNESCO Professor of HIV/AIDS and Heath Security in Africa. He is the author of six books and over fifty articles. In 2017 he received the inaugural special achievement award at the Wales Social Research Awards. Kelley Lee is professor and Tier 1 Canada Research Chair in Global Health Governance in the Faculty of Health Sciences at Simon Fraser University. Her research focuses on the need for collective action to mediate the population health impacts of globalisation. Professor Lee has led major projects on globalisation and health, tobacco control, global health governance, and health diplomacy, based on strong international collaborations. She has held several leadership positions, including as head of a multidisciplinary research group, head of a large department, director of a WHO collaborating research centre, chair of a WHO scientific committee, and associate dean, research. She has authored or co-authored over 120 peer-reviewed papers, more than 60 book chapters, and 14 books. She has received funding from a broad range of research councils, governments, UN organisations, and charitable foundations. Jeremy Youde is dean of the College of Liberal Arts at the University of Minnesota, Duluth. Previously he was an associate professor at the Australian National University and taught at San Diego State University and Grinnell College. His research focuses on questions of global health governance and global health politics. He is the author of four books and co-editor of two recently edited volumes. His most recent book, Global Health Governance in International Society, was published in 2018 with Oxford University Press. He is also chair of the Global Health Section of the International Studies Association. He earned his BA in political science and global development studies at Grinnell College, his MA in political science at the University of Iowa, and his PhD in political science (emphases in international relations and comparative politics) at the University of Iowa.

Contributors

Obijiofor Aginam, United Nations University Solomon Benatar, University of Cape Town; University of Toronto Stuart Blume, University of Amsterdam Kent Buse, UNAIDS Marcos Cueto, Oswaldo Cruz Foundation Sara E. Davies, Griffith University Christian Enemark, University of Southampton Joseph Gafton, Queen Mary University of London Stephen Gill, York University Jeffrey A. Griffin, University of Nevada, Reno Rachel Hammonds, University of Antwerp Tine Hanrieder, WZB Berlin Social Science Center Andrew Harmer, Queen Mary University of London Sarah Hawkes, University College London Benjamin Hawkins, London School of Hygiene and Tropical Medicine Chris Holden, University of York Yanzhong Huang, Seton Hall University Alan Ingram, University College London Adam Kamradt-Scott, University of Sydney Jonathan Kennedy, Queen Mary University of London Akram Khazatzadeh-Mahani, University of Calgary Ronald Labonté, University of Ottawa Kelley Lee, Simon Fraser University Roger Magnusson, University of Sydney

xii   contributors David McCoy, Queen Mary University of London Colin McInnes, Aberystwyth University Suerie Moon, Graduate Institute of International and Development Studies, Geneva João Nunes, University of York Gorik Ooms, London School of Hygiene and Tropical Medicine Robert L. Ostergard Jr., University of Nevada, Reno Peter Piot, London School of Hygiene and Tropical Medicine Arne Ruckert, University of Ottawa Jennifer Prah Ruger, University of Pennsylvania Simon Rushton, University of Sheffield David Sanders, formerly of University of the Western Cape; University of Cape Town Ted Schrecker, Newcastle University Yusra Ribhi Shawar, Johns Hopkins University Jeremy Shiffman, Johns Hopkins University Diego S. Silva, Simon Fraser University; University of Sydney Frank Smith, University of Sydney Julia Smith, Simon Fraser University Stephanie L. Smith, University of New Mexico Jeremy Snyder, Simon Fraser University Matthew Sparke, University of California, Santa Cruz Ellen ‘t Hoen, University of Groningen Alan Whiteside, Wilfrid Laurier University Jeremy Youde, University of Minnesota, Duluth

Foreword Peter Piot

Politics is at the heart of global and public health; scientific evidence alone is very desirable but is insufficient for setting policy and changing practise, and politics can be dangerous if it rejects scientific evidence. From tobacco control to vaccine delivery, we have repeatedly seen that political movements, action, and leadership are an integral part of achieving global health goals. As executive director of UNAIDS, I witnessed first-hand what is possible for public health when politics, science, and people-centred action converge on the ground. The response to HIV/AIDS is one of the most striking examples of politics as a driver of both action and impact and inaction and denial. Take the case of antiretroviral medicines. One of my top priorities at UNAIDS was to negotiate a reduction in the price of treatment, which involved navigating the choppy waters of so-called good and bad politics.1 This tension is even more dramatic when it comes to prevention, where on the one hand, ‘good’ politics is based on evidence-based programmes to reduce HIV infection through sexual transmission or through injecting drug use, whilst on the other hand, ‘bad’ politics was responsible for sidelining scientific evidence and blocking critical policy developments to expand treatment access in South Africa and to prevent HIV amongst people who inject drugs in Russia or gay men and other men who have sex with men in numerous countries. Similar tensions are rife when it comes to prevention of obesity, diabetes, cancers, and other chronic conditions. Navigating these contradictions is of course central to the process of achieving global health goals; however, the role of politics is still underappreciated in many public health circles. Key turning points in the global AIDS response came in 2000 when the United Nations (UN) Security Council debated a health issue for the first time in history and unanimously adopted Resolution 1308, which recognised the severity of AIDS, and in 2001 when the Caribbean Community (CARICOM), the Organisation of African Unity, and a UN General Assembly Special Session all expanded the AIDS response beyond the health community, which laid the foundation for current achievements. This opened many doors for the global response and thrust AIDS into ‘high politics’, where I believe global health issues rightly belong.

xiv   foreword I therefore welcome this timely and important handbook, which collates and analyses key themes and issues in global health politics but also contributes new insights that advance the field. Addressing topics from the politics of agenda setting in global health to celebrity and global health advocacy, this collection of thirty-four essays offers a vital resource for a diversity of readers. Its relevance extends beyond academia; Colin McInnes, Kelley Lee, and Jeremy Youde have clearly articulated the case for action as a cross-cutting theme throughout the edited collection, offering practical insight into how decisions are made in global health and how these decisions can make an impact on the ground. I highly recommend this handbook to researchers, students, policymakers, practitioners, and all of those with an interest in global health. I trust that it will be as thought provoking for you as it has been for me, and that it encourages us all to be more active in policy and politics with the aim of delivering results for people on the ground.

Note Peter Piot is Director of the London School of Hygiene and Tropical Medicine and Founding Executive Director of UNAIDS. 1. Peter Piot, Sarah Russell, and Heidi Larson, “Good Politics, Bad Politics: The Experience of AIDS.” American Journal of Public Health 97, no. 11 (2007): 1934–1936.

chapter 1

Gl oba l H e a lth Politics An Introduction Colin M c Innes, Kelley Lee, and Jeremy Youde

Global health politics has emerged over the course of the last two decades as a distinct and interdisciplinary field of study. This has been underpinned by a shift in the nature of collective action concerned with health, not least as part of the broader zeitgeist of globalisation (McInnes and Lee  2012). Human health has been recognised as being affected by, but also contributing to, processes of globalisation both materially (through phenomena such as the globalised operations of the pharmaceutical industry, the increased speed and reach of disease outbreaks, and the initiation of global governance responses) and discursively (through how the world is described and understood in  research and policy, such as UK government statements that ‘health is global’) (UK DoH 2008). This shift accelerated during the early 2000s such that, by the end of the decade, a consensus existed that a wide range of health issues—from antimicrobial resistance to zoonotic diseases—can no longer be viewed solely through a national lens or be addressed effectively only by international cooperation between states. Rather, broad ranges of health determinants and outcomes have become ‘global’, and thus the political actors and governance processes concerned with addressing them also require new thinking and practises. Emerging from these developments over the past two decades, global health politics is now established as an important field of study, and we see evidence of its maturation in a variety of ways. The field attracts a growing number of students, new courses and degree programmes are appearing in universities around the world, leading journals frequently publish articles focused on global health politics, and panels on global health politics are appearing at major academic conferences (Davies et al. 2014, 826–827). We are also witnessing the emergence of a number of interrelated subfields that shape the field of global

2   COLIN McINNES, KELLEY LEE, AND JEREMY YOUDE health politics. These include globalisation and health (Hanefeld 2015; Lee 2003); the relationships between global health and foreign policy, security, and development (Davies  2019 Price-Smith  2010; Youde and Rushton  2014; global health governance (Harman  2012; McInnes et al.  2014; McInnes and Lee  2015; Youde  2012; Kickbusch 2005); the global political economy of health (Schrecker and Bambra 2015); and policy debates focused on specific issues such as HIV and AIDS (Anderson and Patterson 2017 Dionne 2018), pandemic influenza (Kamradt-Scott and Lee 2011), tobacco control (Lee and Hawkins 2016), access to medicines (Roemer-Mahler 2014), health inequities (Ruckert and Labonte  2017; Benatar  2016), mental health (Howell  2011), Ebola (Gronke 2015), biosecurity (Enemark 2017; Osterholm and Olshaker 2017), legal and ethical frameworks (Poku and Sundewall 2018; Ruger 2012), and non-communicable diseases (Reubi et al. 2016). Even more tellingly, the field is now engaging in critical examinations of itself (Brown, Craddock, and Ingram 2012; McInnes and Lee 2012; Davies et al. 2014). The dynamism of global health politics as a field makes this an important time to ­publish a Handbook that brings together the current state of this scholarship. At the same time, this dynamism necessarily colours its current construction. This Handbook captures a particular moment in this field’s development when it is beginning to demonstrate signs of maturity and its boundaries and constituent elements are formative. We thus do not want to suggest that the field is fixed. Indeed, the range of issues constituting the field of global health is far from settled. When we began this venture, the 2014–2016 outbreak of Ebola virus in West Africa was waning, the Zika virus crisis was beginning, the Rockefeller-Lancet Commission on Planetary Health (see ‘Safeguarding Human Health’ 2015) had just commenced its work, and the UN General Assembly’s High Level Meeting on antimicrobial resistance had yet to take place. We have little doubt that the political agenda in global health will continually change and be reshaped by new challenges that emerge. At the same time, scholarly debates within subfields, including over the nature and extent of the field, remain far from settled. Major works were published whilst this Handbook was being prepared (e.g., Davies 2019; Dionne 2018; Patterson 2018) and will continue to appear after its publication. There are also important debates emerging about the need to decolonise global health as a field of study and practise: To what extent does existing scholarship too blithely sustain, replicate, and even exacerbate existing power differentials within the global system (Biehl 2016; Birn 2014; Waitzkin 2015)? An orthodoxy is emerging over the focus areas of the field and, like all orthodoxies, it is generating its discontents, who are pushing at the boundaries and critiquing the nature of the field (see, e.g., Birn, Pillay, and Hotz 2017). This dynamic and formative scholarship is what this Handbook attempts to capture and articulate in its present form. This volume is intended as both an assessment of the state of the field and, we hope, a distinct contribution to advancing that field. The latter ambition, in turn, comprises two elements, presenting an understanding of what the field is, together with its major subfields and critical perspectives, at a point of immanent maturity, and how individual essays further understanding of issues comprising the field and its subfields.

Global Health Politics: An Introduction   3

The Meanings of Global Health and Global Health Politics Global health can be broadly defined as the health of human populations within a worldwide context. More specifically, it concerns those health determinants and outcomes that extend across and beyond defined geographical territories (especially the political boundaries of states) to address the world as a territorial whole and even as a deterritorialised space. It builds on a substantial and well-established literature on local and national health politics (Immergut 1992), but expands upon it by emphasising this de/reterritorialised nature of health determinants and outcomes, the broadening range of state and non-state actors involved in health policy and practise, and the reciprocal relationship with other policy spheres. In so doing, it draws heavily on thinking about globalisation and its broader societal effects across the world, which began to influence scholarly thinking in the 1990s (Kirton 2017; Lee 2003; McInnes and Lee 2012). Beyond this broad understanding, however, consensus about the distinct nature of global health becomes more contested and problematic. The term has become ubiquitous in use, often poorly or inaccurately defined, akin to the over- and misuse of the term globalisation (Yach and Bettcher 1998a, 1998b; Kickbusch, Hartwig, and List 2005; Scholte 2008; Labonté 2018). Efforts to resolve this impasse have been valiant (Koplan 2009; Beaglehole and Bonita 2010; Rowson et al. 2012), but ultimately unsuccessful, in critically resolving tensions in past and present theory and practise. These efforts have highlighted the disciplinary differences that now silo global health thinking and practise, notably within and between the biological and clinical medical sciences and the social sciences. This is unfortunate given the wide recognition of how global health necessarily interacts with other policy sectors far beyond health, including foreign policy, security and law enforcement, trade and finance, environment, and development. These interactions in turn add further complexity to defining the boundaries of global health. For example, in development, global health becomes defined as a key element in providing basic needs and reducing poverty; for security, it becomes defined as a source and means of reducing existential threats to the state and the stability of the international order; and in trade and finance, global health becomes defined as a core element in generating macroeconomic growth. Global health politics is concerned with the actions, practises, and policies that govern the sphere of global health. It addresses not only the processes of decision-making by relevant institutional actors, but also the structures of power that shape what is possible. We understand structural factors as ‘social and political mechanisms (governance, macroeconomic policy, social policy, public policy as well as social and cultural values) that generate, configure and maintain socioeconomic position (social class, gender or

4   COLIN McINNES, KELLEY LEE, AND JEREMY YOUDE ethnicity)’ (Krumeich and Meershoek 2014). Global health actors include the state, but also encompass • international (state-to-state or intergovernmental) organisations (such as the World Health Organization [WHO] and the World Bank), • private for-profit entities (such as corporations), • public-private partnerships (such as the GAVI Alliance), • civil society organisations (such as the International AIDS Society and Médicins sans Frontières), • charitable organisations and foundations (such as the Rockefeller Foundation, Rotary International, and the Wellcome Trust), and • individuals wielding normative or material power (such as Bill and Melinda Gates, Michael Bloomberg, and Mark Zuckerberg). Importantly, global health politics is intimately concerned with power in at least two dimensions. First, power is distributed amongst and exercised by global health actors (or agents), but is also embedded within global health structures. The ways in which global health actors (i.e., actors with recognised roles and/or interests in global health) interact within a so-called global health architecture is shaped by their relative power. At the same time, these interactions take place within structures that enable or disable the exercise of that power. Second, power is both material (the distribution of and capacity to access and use resources such as financial and human capital and technology)—and ideational (the distribution of and capacity to access and use ideas in ways that persuade others of the cognitive validity of their worldview) (Carstensen and Schmidt 2016). Ideas shape what are deemed priority needs, agreed policy solutions, or legitimate norms to be pursued in global health. Ideas structure global health by delineating not simply what is desirable but what is possible. For example, the idea of globalisation enables initiatives for the global surveillance of communicable diseases, the idea of health as a human right legitimates the involvement of civil society actors in global heath discussions, and the idea of humanitarianism underpins development aid. But ideas also provide competing understandings about global health within which agents operate. Thus, from the perspective of a right to health, access to medicines is highly desirable, but from a position of international trade, incentivising research and development via patent protection is vital even if it limits affordability by keeping prices higher. In this sense, both material and ideational power interact together to shape the politics of ‘who gets what’ in global health.

The Development of Global Health Politics Global health politics as a field of scholarly inquiry has emerged as a result of not only the discursive shift to ‘global health’, but also the changed political landscape. During the

Global Health Politics: An Introduction   5 twentieth century the dominant discourse presented health primarily as an issue of domestic social policy, with some technical aspects requiring international cooperation, and it focused on the state as provider. By the end of the twentieth and beginning of the twenty-first centuries, however, this perspective was challenged by a series of political developments that provided the permissive atmosphere for the reconceptualisation of health as a global concern. Not least, the post–Cold War world appeared to open the  doors for a ‘new humanitarianism’, exemplified by Tony Blair’s ‘Chicago Speech’ (Blair 1999) and by the UN’s Responsibility to Protect agenda. From this understanding, a belief in the obligation of the rich to help those in need flowed, reaching its high-water mark in the Group of Eight’s Declaration following its 2005 Gleneagles Summit. Fundamental to the Gleneagles Declaration was promoting health, partly as a poverty reduction strategy but also because of concerns over the alarming spread of HIV and AIDS, especially in Africa. Furthermore, the accelerating processes of globalisation appeared to create a situation in which the most pressing challenges were not soluble by states working on their own; rather, global problems required global solutions. The 2002–2003 SARS epidemic and the response to it exemplified how successfully addressing global health requires a collective response and gave a touch of reality to concerns over the potentially rapid and damaging spread of diseases in the twenty-first century. Not only were new diseases appearing more frequently, but responding with appropriate pharmaceutical interventions was becoming more challenging. The high cost of research and development, the consolidation of the pharmaceutical sector into a small number of transnationals, and the networked nature of modern science combined to create a global pharmaceutical sector—even if access to the most modern drugs and health technologies was far from universal. This reinforced the move to global health, but despite advances in drugs and medical technologies, new diseases, drug-resistant strains of existing diseases, and antimicrobial resistance all suggested that pharmaceutical interventions were insufficient on their own to guarantee global health security. Rather, collective action was required to prevent and limit the effects of global health emergencies, requiring a degree of political cooperation. The view of health as a domestic social concern was also accommodated in the ­popular distinction—especially prevalent in the discipline of international relations— between ‘high’ and ‘low’ politics. Whilst high politics dealt with issues of power between states, low politics concerned ways of living and social conditions. Some even called health ‘really low politics’ because it was considered technical, humanitarian, and non-political (Fidler 2005). This perspective has now been usurped, partly through work in other fields that have critiqued the high/low distinction. Arguing that the ‘personal is political’ and that how people live their lives is conditioned by global forces and power inequalities, scholars successfully demonstrated how individual lives are inextricably linked to global forces (e.g., Enloe 2014). But the perspective has also been usurped by linking global health to traditional concerns of high politics such as security, global governance, and foreign policy (McInnes and Lee 2006; Youde 2016; Youde and Rushton 2014). As a result, if health was global, then it was also political, a priority area requiring policy action worldwide.

6   COLIN McINNES, KELLEY LEE, AND JEREMY YOUDE For the policy community, global health has therefore become a subject of heightened concern within the context of post–Cold War geopolitics, intensified globalisation, and growing disparities between the ‘haves’ and ‘have-nots’. Impetus has stemmed from ­perceptions of new transboundary risks from infectious disease outbreaks and new ­patterns of health and disease (epidemiological transition) caused by the effects of globalisation on health determinants such as climate change, corporate marketing, illicit activities, and trade liberalisation. In addition to threatening to reverse advances in basic health indicators achieved over the twentieth century, wider concerns about potential impacts on poverty reduction strategies, macroeconomic growth, and security put global health higher on policy agendas worldwide. Consequently, global health was introduced into national policy statements on development, foreign policy, and security; featured centrally in the Millennium Development Goals and the subsequent Sustainable Development Goals; has risen in prominence on agendas of major international organisations (such as the UN, World Economic Forum, and Group of 8/Group of 7); has led to the creation of a multitude of new global initiatives (e.g., UNAIDS, GAVI Alliance, and Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria); has prompted UN Security Council resolutions; and has defined the activities of new and existing civil society organisations, charitable foundations, and private sector actors.1 This remarkable growth in policy attention originated in part from studies conducted by academics and in policy think tanks that focused on the growing ‘threat’ posed by infectious diseases (see, e.g., Brower and Chalk  2003; Elbe  2003; Garrett  1994,  1996; National Intelligence Council  2000,  2002; Osterholm  2005; and Price-Smith  2001). These studies tended to concentrate on the threat of infectious diseases to high-income countries, which had for several decades been largely protected from these concerns due to improved standards of public health and increased access to medicines such as antibiotics and antivirals. In addition, events such as the 2002–2003 SARS outbreak, the apparent inability to halt the HIV and AIDS pandemic in sub-Saharan Africa, the fears about the emergence of pandemic influenza, the linkage drawn between improvements in health and macroeconomic growth (WHO, 2001), and fears over bioterrorism (especially after the September 11, 2001, attacks and the anthrax letters in the United States) provided sustained impetus for world leaders to address global health issues in the years surrounding the turn of the new millennium. This in turn prompted academic inquiry into global health in general and the politics surrounding it more specifically. However, a simple binary between the worlds of academia and policy/practise fails to reflect the close relationship between the two. Although not a ‘revolving door’, academics have held senior posts in the policy world, policymakers have entered or returned to the academic world, some straddle both simultaneously, and yet others operate in the ‘grey area’ of think tanks. For example, Peter Piot, a Belgian scientist, led UNAIDS from 1995 to 2008 before returning to academia as director and Handa Professor of Global Health at the London School of Hygiene and Tropical Medicine (LSHTM). Laurie Garrett started her career as a science and medicine reporter for Newsday before directing the Global Health Program at the Council on Foreign Relations from 2004 to 2016. David Heymann initially worked as a medical epidemiologist with WHO’s smallpox

Global Health Politics: An Introduction   7 eradication campaign in India before working for the Centers for Disease Control and Prevention (CDC) and the WHO Communicable Disease Cluster. Since leaving WHO, he has directed the Centre on Global Health Security at Chatham House, served as the chair of Public Health England, and held an appointment as professor of infectious disease epidemiology at LSHTM. David Fidler, as a law professor at Indiana University, has also advised top policymakers with the CDC, WHO, and UN Secretary-General. He is also an adjunct fellow with the Council on Foreign Relations. Ilona Kickbusch held senior roles with WHO during the 1980s and 1990s before leaving to start the Global Health Program at the Yale School of Public Health in 1998 and then taking her current position as the director of the Global Health Centre at the Graduate Institute of International and Development Studies in Geneva. Building upon their connections in both the policy and academic realms, Kickbusch and Heymann worked together to develop a crisis simulation during the G20 Health Ministers meeting in 2017. These connections have allowed for a degree of cross-fertilisation between the academic and policy spheres.

The Structure of the Handbook The study of global health is located at the intersection of several academic subjects and disciplines. At its heart are the biomedical sciences and public health, given their efforts to understand, develop, and implement effective measures to protect and promote population health amid globalisation. The field of global health politics involves a similarly multi- and interdisciplinary breadth, including • political science and especially international relations (given its interest in power, security, rights, and governance at the international and global levels), • development studies (given the marked rise of health development aid since the 1990s), • economics (given the importance attributed to healthy populations for economic growth and prosperity), • anthropology (given the variety of understandings of health and disease around the world and the challenges of external actors providing health services in communities), and • public administration (given efforts to strengthen and reform the performance of global health institutions). At the heart of this, however, are the disciplines of politics and, especially, international relations. The study of both politics and international relations dates back over centuries, and the disciplines have developed sophisticated methods and ideas, controversies, and insights into the workings of power; how decisions are made; questions of rights and responsibilities; and understanding who gets what, how, and why at multiple

8   COLIN McINNES, KELLEY LEE, AND JEREMY YOUDE levels of analysis (i.e., to employ a perhaps overused phrase, ‘from the local to the global’). These are precisely the concerns of global health politics, and it is therefore entirely appropriate that these disciplines, politics and international relations, and their ideas should provide a core of knowledge and understanding to the field. Works on global health politics do not always demonstrate this underpinning awareness of the disciplinary expertise in political science and international relations (Paxton and Youde 2018). Nevertheless, an understanding of the nature of politics and the workings of power appears to us to be fundamental to the study of global health politics. But equally the field cannot be limited to this; to use Kenneth Waltz’s well-known aphorism, it is necessary but not sufficient. Rather, the field requires knowledge and techniques from a variety of disciplines, which intersect to produce a more complete understanding of global health politics than any one discipline can provide. The result of this intersection is a field that is inherently both multi- and interdisciplinary. It is also characterised by methodological pluralism and varied theoretical perspectives: from positivism and empirical studies, to critical theory and social constructivism. This Handbook seeks to capture both the benefits of and complications arising from this intellectual diversity. We have organised the Handbook into five sections. The first (this chapter) outlines our understanding of the field and reflects on its development at a particular moment. The second section charts the shift from international to global health and introduces two themes that are central to the study of global health politics as a whole. The first is that of power. The determinants and outcomes of global health are not equal, nor is the manner in which issues are constructed and solutions articulated. The nature of global health is intrinsically political, reflecting power relations which play a significant role in whether various groups can set the political agenda and/or claim resources. Second, we introduce ideas of critical thought, which are then pursued in more detailed chapters elsewhere in the volume. This is important both to the Handbook and to the field in problematising what are seen as ‘givens’, in asking questions about the perceived nature of the material world, and in opening up a space for different ways of seeing the world of global health. For us, this is a part of global health politics not in the Kantian sense of critique—that global health politics is about the application of reason and the use of rationality to solve problems—but, as Alan Ingram states ‘to approach global health critically is to appreciate that any analysis of global health takes place in the midst of power relations, power struggles and political events’ (see Ingram, this volume). Not least, thinking critically challenges the manner in which power structures establish what is considered acceptable. It suggests that ‘common sense’ is not an objective assessment of an independent material world, but rather a construction ‘for someone and for some purpose’, to use Robert Cox’s famous trope (Cox 1981, 128). The third section examines the politics of how global health has influenced, been affected by, and sometimes become part of other policy arenas. Indeed, one of the tensions in global health politics is whether linkage to these other policy arenas—such as international development and security—provides additional leverage for global health, allowing it to become more prominent on political agendas, or means that health is

Global Health Politics: An Introduction   9 subsumed under other priorities. The fourth section addresses global health governance: the institutional actors and structures that govern global health, their ability to establish rules and norms of behaviour that transcend the state, and what this reveals about power relations in global health. The final section discusses key issues that have occupied global health politics and have thus featured in the existing literature and policy debates. This section is not intended to be comprehensive, but rather indicative of both the types of complex issues that occupy the heart of this field of study and practise and the different ways in which they have been studied.

Pondering the Future(s) of Global Health Politics Identifying where the future of the field might lie risks a form of intellectual path de­pend­ency—that we extrapolate from current trends and assume that these will determine the future. Although genuinely disruptive events can, of course, only be ­predicted in hindsight, even existing trends may move in unpredictable directions. Nevertheless, a number of questions do suggest themselves as being significant for the future of the field. First, as previously noted, global health politics as a field is dominated by the voices of a privileged few, which is inherently problematic. Crudely put, many of the scholarly voices in global health politics are white and male (including two of the authors of this chapter). Notwithstanding the sincere commitment of many of these people to improving global health, the power to shape the scholarly and policy agenda worldwide remains highly skewed in favour of a relative few. How might greater diversity of scholarship be supported, addressing intersectional categories of marginalisation by geography, race, gender, and socioeconomic status? There are growing efforts to broaden the diversity of voices heard by gender, for example through the creation of several lists recognising female leadership in global health, including academia. Most of these lists, however, have so far had limited success in addressing intersectionality. Therefore, although encouraging trends are apparent, the degree to which decolonising the scholarly agenda will be realised is still uncertain. Second, existing global health governance institutions, many of which have been created since the late twentieth century, have faced closer scrutiny regarding their internal governance. First, WHO has been the subject of long-standing scrutiny focused on its mandate and performance, and amid the proliferation of other, sometimes competing global health actors. Searing criticism of its response to the Ebola virus outbreak in West Africa has prompted yet further calls for reform to strengthen the organisation’s capacity (Busby et al. 2016; Moon et al. 2015). WHO is not alone, however, in facing greater scrutiny. A 2017 report on fraud and corruption in the use of funds disbursed by the Global Fund prompted an internal Governance Review and

10   COLIN McINNES, KELLEY LEE, AND JEREMY YOUDE Action Plan (Global Fund to Fight AIDS, Tuberculosis, and Malaria, Office of the Inspector General  2017). A blunt independent investigation in 2018 of harassment and  bullying by UNAIDS senior officials has raised broader questions about the appropriateness of a disease-specific initiative (UNAIDS Programme Coordinating Board 2018). Which institutions will emerge as the key players in global health governance in the coming years? Third, the broader context within which global health politics occurs is changing in several potentially significant ways. China’s continued political and economic rise may challenge long-standing distributions of power in global health. The creation of the Asian Infrastructure Investment Bank in 2016 represents a new multilateral development financial institution that could compete with the World Bank and International Monetary Fund (Dahir 2018). As China has assumed a more prominent global role, it has also shown an interest in global health governance, though it has tended to prioritise its own bilateral initiatives over existing institutions (Chan  2011). Furthermore, the success of populist movements around the world—from Donald Trump’s successful presidential campaign in the United States, to Brexit in the UK, to the election of farright politician Jair Bolsonaro to the presidency of Brazil, to the significant increase in support for far-right Eurosceptic parties across Europe—suggests the emergence of a strong constituency disillusioned with the effects of globalisation. The very countries that have played such important roles in creating and sustaining global health governance institutions and laying the foundations for the successes achieved so far are now openly questioning the usefulness of these organisations, and of multilateralism and globalisation in general. This is not to say that we are witnessing the end of globalisation, but that it has reached a new phase that includes potential changes to the structures, norms, and funding systems that have supported global health governance thus far. When global health politics started to come into its own as a field, globalisation was the dominant geopolitical narrative. Recent political changes now hint that this agenda is more contested. Fourth, if the narrative of globalisation is being questioned from a resurgent nationalism, then equally it is being taken in new directions with the emergence of a ‘planetary’ agenda. If globalisation focused on the increased speed and intensity of human interactions on a global scale, ‘planetary politics’ firmly places animal and environmental factors in the mix. For some, such as the Rockefeller Foundation-Lancet Commission on Planetary Health, this is largely about how global environmental developments (particularly related to climate change and the food chain) will affect human development and health (Horton et al. 2014; ‘Safeguarding Human Health’ 2015). For others, it is a much more radical reimagining of the political (e.g., Burke et al. 2016). For health, this is seen in the ‘One Health’ agenda, in which the politics surrounding animal welfare and the environment are integral elements to understanding global health. Fifth, the field of global health politics is presently largely characterised by a mix of multi- and interdisciplinary work. As is evident in this volume, some chapters can be readily accommodated within single disciplinary perspectives. Others, despite drawing on elements from several disciplines, are clearly ‘majoring’ in one; some—probably the minority—are fundamentally interdisciplinary. That the field is so inherently open

Global Health Politics: An Introduction   11 to interdisciplinary research begs the question of whether the move from multi- to interdisciplinarity will accelerate, or the structure of research will compromise these moves. Can (or should) a genuinely transdisciplinary field of global health politics ultimately emerge? Although major interdisciplinary funding initiatives are increasing, structural factors and disciplinary gatekeeping still limit the development of genuine interdisciplinarity. Finally, the one thing that we can confidently predict is that new health issues will continue to emerge for global health politics to negotiate. This includes new patterns of health and disease, emerging and re-emerging disease threats, existing issues breaking through the glass ceiling of political awareness (such as antimicrobial resistance), and the emergence of unimagined problems (where, for example, will artificial intelligence lead? or genetic manipulation?). Perhaps equally unpredictable yet expected will be changes within the broader political context. What will be the dominant changes in the political zeitgeist at both the national and global levels? How will the growing effects of climate change influence international and domestic politics? These are some of the ‘known unknowns’ of global health. But there are also ‘unknown unknowns’, which might have dramatic and far-reaching effects. As a result, we need to consider how we understand the need for political systems that are flexible enough to adapt to the new challenges that will emerge.

Conclusion: Politics and Global Health Politics is often perceived as a negative force by global health policymakers and practitioners, an interference with achieving effective ‘evidence-based’ action. Commentators and practitioners talk about the need to ‘get politics out of global health’ and instead enable scientific rationality to guide action. We argue—and this Handbook hopefully demonstrates—that politics is not only unavoidable, but necessary and integral to effectively addressing global health challenges. The study of global health politics is not about how to minimise interference in rational decision-making, but rather how to improve the quality of political institutions and processes that will in turn improve global health actions and ultimately outcomes. This is why more rigorous and thorough scholarship is needed. Global health politics is a new field embodying a wide range of questions—and does not (yet) have answers for many of them. Our hope is that this Handbook will help scholars, policymakers, and practitioners understand how the field has emerged, appreciate where it is now, and inspire vitally needed research in future.

Note 1. On these developments, see, for example, McInnes and Lee (2012); Davies (2010); and Youde (2012).

12   COLIN McINNES, KELLEY LEE, AND JEREMY YOUDE

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Global Health Politics: An Introduction   13 Fidler, David  P. 2005. ‘Health as Foreign Policy: Between Principle and Power.’ Whitehead Journal of Diplomacy and International Relations 6: 179–194. Garrett, Laurie. 1994. The Coming Plague: Newly Emerging Diseases in a World Out of Balance. New York: Penguin. Garrett, Laurie. 1996. ‘The Return of Infectious Disease.’ Foreign Affairs 75: 66–79. Global Fund to Fight AIDS, Tuberculosis, and Malaria, Office of the Inspector General. 2017. Governance Review: Proposed Improvements for the Board and Its Committees. Geneva: Global Fund to Fight AIDS, Tuberculosis, and Malaria. https://www.theglobalfund.org /media/7826/oig_gf-oig-17-009_report_en.pdf?u=636784021680000000. Gronke, Paul. 2015. ‘The Politics and Policy of Ebola.’ PS: Political Science and Politics 48: 3–17. Hanefeld, Johanna. 2015. Globalisation and Health. 2nd ed. London: Open University Press. Harman, Sophie. 2012. Global Health Governance. New York: Routledge. Horton, Richard, Robert Beaglehole, Ruth Bonita, John Raeburn, Martin McKee, and Stig Wall. 2014. ‘From Public to Planetary Health: A Manifesto.’ Lancet 383: 847. Howell, Alison. 2011. Madness in International Relations: Psychology, Security, and the Global Governance of Mental Health. New York: Routledge. Immergut, Ellen. 1992. Health Politics, Interests and Institutions in Western Europe. Cambridge, UK: Cambridge University Press. Kamradt-Scott, Adam and Kelley Lee. 2011. ‘The 2011Pandemic Flu Preparedness Framework’. Political Studies 59: 831–847. Kickbusch, Ilona. 2005. ‘Action on Global Health: Addressing Global Health Governance Challenges.’ Public Health 119: 969–973. Kickbusch, Ilona, Kari Hartwig, and Justin List, eds. 2005. Globalization, Women, and Health in the Twenty-First Century, New York: Palgrave Macmillan. Kirton, John J., ed. 2017. Global Health. Abingdon, UK: Taylor and Francis. Koplan, Jeffrey, Christopher Bond, Michael  H.  Merson, K.  Srinath Reddy, Mario Henry Rodriguez, Nelson K. Sewankambo, Judith N. Wasserheit. 2009. ‘Towards a common definition of global health.’ The Lancet 373: 1993–1995. Krumeich, Anja, and Agnes Meershoek. 2014. ‘Health in Global Context: Beyond the Social Determinants of Health?’ Global Health Action 7: 23506. doi:10.3402/gha.v7.23506. Labonté, Ronald. 2018. ‘Reprising the Globalization Dimensions of International Health.’ Globalization and Health 14: 49. doi:10.1186/s12992-018-0368-3. Lee, Kelley. 2003. Globalization and Health: An Introduction. New York: Palgrave Macmillan. Lee, Kelley, and Benjamin Hawkins. 2016. Researching Corporations and Global Health Governance: An Interdisciplinary Guide. London: Rowman and Littlefield. McInnes, Colin, Adam Kamradt-Scott, Kelley Lee, Anne Roemer-Mahler, Simon Rushton, and Owain  D.  Williams. 2014. The Transformation of Global Health Governance. Basingstoke, UK: Palgrave. McInnes, Colin, and Kelley Lee. 2006. ‘Health, Security, and Foreign Policy.’ Review of International Studies 32: 5–23. McInnes, Colin, and Kelley Lee. 2012. Global Health and International Relations. Cambridge, UK: Polity. McInnes, Colin, and Kelley Lee, eds. 2015. Framing Global Health Governance. Abingdon, UK: Routledge. Moon, Suerie, Devi Sridhar, Muhammad  A.  Pate, Ashish  K.  Jha, Chelsea Clinton, Sophie Delaunay, et al. 2015. ‘Will Ebola Change the Game? Ten Essential Reforms before the Next Pandemic: The Report of the Harvard-LSHTM Independent Panel on the Global Response to Ebola.’ Lancet 386: 2204–2221.

14   COLIN McINNES, KELLEY LEE, AND JEREMY YOUDE National Intelligence Council. 2000. The Global Infectious Disease Threat and Its Implications for the United States. Washington, DC: National Intelligence Council. National Intelligence Council. 2002. The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India, and China. Washington, DC: National Intelligence Council. Osterholm, Michael T. 2005. ‘Preparing for the Next Pandemic.’ Foreign Affairs 84: 24–37. Osterholm, Michael  T., and Mark Olshaker. 2017. Deadliest Enemy: Our War Against Killer Germs, New York: Little, Brown and Company. Patterson, Amy S. 2018. Africa and Global Health Governance: Domestic Politics and International Structures. Baltimore, MD: The Johns Hopkins University Press. Paxton, Nathan, and Jeremy Youde. 2018. ‘Engagement or Dismissiveness? Intersecting International Theory and Global Health.’ Global Health 14: 503–514. Poku, Nana, and Jesper Sundewall. 2018. ‘Political Responsibility and Global Health.’ Third World Quarterly 39: 471–486. Price-Smith, Andrew T. 2001. The Health of Nations: Infectious Disease, Environmental Change, and Their Effects on National Security and Development. Cambridge, MA: MIT Press. Price-Smith, Andrew T. 2010. Contagion and Chaos: Disease, Ecology, and National Security in the Era of Globalization. Cambridge, MA: MIT Press. Reubi, David, Clare Herrick, and Tim Brown. 2016. ‘The Politics of Non-communicable Diseases in the Global South.’ Health and Place 39: 179–187. Roemer-Mahler, Anne. 2014. ‘The Rise of Companies from Emerging Markets in Global Health Governance: Opportunities and Challenges.’ Review of International Studies 40: 897–918. Rowson, Mike, Chris Willott, Rob Hughes, Arti Maini, Sophie Martin, J. Jaime Miranda, et al. 2012. ‘Conceptualizing Global Health: Theoretical Issues and Their Relevance for Teaching.’ Globalization and Health 8: 36. doi:10.1186/1744-8603-8-36. Ruckert, Arne, and Ronald Labonté. 2017. ‘Health Inequities in the Age of Austerity: The Need for Social Protection Policies.’ Social Science and Medicine 187: 306–311. Ruger, Jennifer Prah. 2012. ‘Global Health Justice and Governance.’ American Journal of Bioethics 12: 35–54. ‘Safeguarding Human Health in the Anthropocene Epoch: Report of The Rockefeller Foundation–Lancet Commission on Planetary Health.’ 2015. The Lancet, July 16. https: //www.thelancet.com/commissions/planetary-health. Scholte, Jan Aart. 2008. ‘Defining Globalisation.’ The World Economy 31: 1471–1502. Schrecker, Ted, and Clare Bambra. 2015. How Politics Makes Us Sick: Neoliberal Epidemics. New York: Palgrave Macmillan. UK DoH [Department of Health]. 2008. Health Is Global. London: HMSO. UNAIDS Programme Coordinating Board. 2018. Report on the Work of the Independent Expert Panel on Prevention of and Response to Harassment, Including Sexual Harassment; Bullying; and Abuse of Power at UNAIDS Secretariat. Geneva: UNAIDS. http://www .unaids.org/sites/default/files/media_asset/report-iep_en.pdf. Waitzkin, Howard. 2015. Medicine and Public Health at the End of Empire. New York: Routledge. World Health Organization (WHO). 2001. Macroeconomics and Health: Investing in Health for Economic Development. Report of the Commission on Macroeconomics and Health. Geneva: WHO. Yach, Derek, and Douglas Bettcher. 1998a. ‘The Globalization of Public Health I: Threats and Opportunities.’ American Journal of Public Health 88: 735–744.

Global Health Politics: An Introduction   15 Yach, Derek, and Douglas Bettcher. 1998b. ‘The Globalization of Public Health II: The Convergence of Self-interest and Altruism.’ American Journal of Public Health 88: 738–744. Youde, Jeremy. 2012. Global Health Governance. Cambridge, UK: Polity. Youde, Jeremy. 2016. ‘High Politics, Lower Politics, and Global Health.’ Journal of Global Security Studies 1: 157–170. Youde, Jeremy, and Simon Rushton, eds. 2014. Routledge Handbook of Global Health Security. Abingdon, UK: Routledge.

PA RT I

F ROM I N T E R NAT IONA L TO GL OBA L H E A LT H

chapter 2

The History of I n ter nationa l H e a lth Medicine, Politics, and Two Socio-Medical Perspectives, 1851 to 2000 Marcos Cueto

Although maritime sanitation rules in port cities have existed since the Middle Ages, international health became a sustained intergovernmental activity only in the midnineteenth century. During the past few years historical studies have examined this more recent period to determine how international health intertwined with imperialism, philanthropy, humanitarianism, multilateralism, bilateralism, decolonisation, and development (Amrith 2006; Birn 2009; Black 1996; Farley 2004; Harrison 2012; Packard 2016; Watts 1997). These studies examine the process, from ineffectual agreements in response to epidemic outbreaks to permanent institutions. As an addition to this historiography, this chapter argues that two visions ran parallel to one another in this proc­ess. The first, hegemonic perspective was based on an excessive reliance on Western medical technology and validated international health as a contribution to global economic growth. The second perspective placed an emphasis on holistic interventions, social reforms to improve people’s welfare, and solidarity between countries. These visions are examined, first, in the relationship between imperialism and the first international health agreements and institutions of the nineteenth and turn of the twentieth centuries; and second, in the coexistence of different proposals during the interwar period (1919–1939). I also analyse how these visions reflected and interacted with the Cold War and health multilateralism, especially in the development of the World Health Organization (WHO), a United Nations agency created in 1948. Finally, the chapter studies the changes and continuities of the new field of global health that emerged in the late 1980s and was closely related to the emergence of neo-liberalism.

20   Marcos Cueto

From International Agreements to Specialised Institutions Pandemics—epidemics that affect several countries simultaneously—massive migration, and the expansion of maritime commerce, especially with colonial ports, stimulated the first coordinated governmental decisions on international health. That was the case with cholera, the most important pandemic of the nineteenth century. The disease, which could be easily identified by the violent diarrhoea and other dramatic symptoms that it produced, was new to Europe and was presumed to have come from India (where it was endemic) by means of steamships. From 1851 onward, governments, mainly of Western Europe and the United States, organised a series of International Sanitary Conferences (eleven by 1913). Initially the objectives of these conferences were to improve and regulate quarantines and standardise compulsory isolation measures for passengers suspected of having cholera (Howard-Jones 1975; Stern and Merkel 2004). They made progress in overcoming the ambiguous, erratic, and controversial maritime quarantine practises, land controls, and compulsory isolation hospitals of the turn of the nineteenth century and facilitating national consensus amongst merchants, diplomats, and health leaders. The agenda of these meetings was set by the imperial European powers and the priorities of European tropical medicine regarding the protection of industrialised nations from diseases coming from abroad, the protection of colonisers, the improvement of colonial economies, and the construction of an image of ‘humanitarianism’ to validate the colonial enterprise. It was also important to establish outposts in Africa, Asia, and other tropical regions of the world as medical research enclaves that would produce results to be published in the metropolis and enhance the scientific prestige of Western medicine. Some success occurred in articulating maritime sanitation with the economic interests of merchants, who used to reject any sanitary control of goods and passengers (Hardy 1993), although the confrontation of stigma and discrimination—which usually blamed foreigners and the poor for epidemics—received less attention. However, effective decisions were made slowly because there was no agreement on what to do. Initially, the first sanitary conferences achieved little consensus because of disagreements between diplomats and physicians and debates amongst medical doctors. For example, it took some time for many representatives at the conferences to accept the findings of British doctor John Snow, who since 1850 had argued that cholera could spread in cities in water contaminated with faeces of sick people (meaning that safe water and sewage systems were the most effective control measures). Instead, many physicians argued that the disease was not transmitted by direct exposure but had a miasmatic origin in garbage and filth and could be addressed only with local hygiene. International health experts’ attention was not solely focused on cholera, however. In 1871 a yellow fever epidemic killed thousands of people in Buenos Aires, Argentina, proving that the illness was not limited to the Caribbean—as previously believed—and

History of International Health   21 could spread to other parts of the world. The Americans and Cubans pushed for the inclusion of yellow fever on the agendas of international conferences. A physician who played an important role in this process was the Cuban Carlos Finlay, who argued at the 1881 Washington, DC, sanitary conference that the Aedis aegypt mosquito was responsible for transmitting yellow fever and that controlling the mosquito population was therefore essential for controlling disease transmission. His finding was part of a moment of ineffective agreements on international health; at this same conference, for example, the US government failed to obtain the support of other governments for a bill of health for any ship travelling to America. Experimental evidence on Finlay’s work appeared only years later, thanks to a US military commission led by Walter Reed, who worked in Havana in 1900 in the wake of Cuba’s war of independence from Spain (Espinosa 2009). These works inspired and helped public health physicians to reduce the incidence of yellow fever in Havana and in cities of the Americas. In addition to cholera and yellow fever, a third contagious disease was the subject of meetings at the beginning of the twentieth century: bubonic plague. The illness spread from Asia to the rest of the world, along with stigma against Asians (Echenberg 2007). Between 1895 and 1914 it seriously affected a number of countries, including Portugal, Australia, South Africa, the United States, Brazil, Paraguay, Peru, and Argentina. Thanks to earlier efforts to stem yellow fever and the plague, as well as the advance of bacteriology in medical schools, vector control was less controversial than it had been during earlier debates about cholera. In Hong Kong and India, researchers in bacteriology and parasitology showed that the plague was produced by bacteria that were transmitted to humans through fleas found on rats. These discoveries led to public health measures to control the plague, including the elimination of rats in ports, a serum to treat the disease, and improved urban hygiene. These medical developments occurred in a more permissive context for international health decisions. For example, the seventh International Sanitary Conference, in 1892, approved a quarantine agreement for the Suez Canal (which had been in operation since 1869 and was perceived by many experts to be cholera’s entry point to Western Europe). The sanitary conference of 1897 adopted another convention to control plague. To enlarge the work of sanitary conferences, governments and medical leaders of Europe and the United States decided in 1903 to consolidate all previous agreements in the International Sanitary Convention (later called International Sanitary Regulations and then International Health Regulations [IHRs]). The decision also entailed the creation of a clearinghouse organisation to centralise and ratify available data on epidemic outbreaks and supervise the implementation of the 1903 Convention. These were the origins of the Office International d’Hygiène Publique (OIHP). The new agency operated in Paris between 1907 and 1946, with a permanent secretariat and with regular meetings of a committee of diplomats and public health officers. Because a significant number of its officers were diplomats, it was an agency in which political and medical goals coexisted on difficult terms (Paillete 2014). Its authority was also weakened by World War I (1914–1918), during which there was little cooperation amongst European nations, whilst at the end of the war other agencies arose. Since 1919, for example, the

22   Marcos Cueto humanitarian International Federation of Red Cross Societies has been responsible for bringing together voluntary work, whilst in Geneva the League of Nations established its own health body (the League of Nations Health Organization [LNHO]). Despite the fact that the United States chose not to join the League of Nations because of its isolationist policies during this period, US health authorities were part of both the LNHO and the OIHP (Borowy 2009a). Because of hostilities between member countries of the two agencies, it was not possible to merge the LNHO and the OIHP. (France, for example, was a defender of the OIHP but did not agree with the LNHO.) However, the leader of the LNHO, Ludwik J. Rajchman, was a Polish doctor who became a champion in addressing the international spread of disease by research, by helping the investigation to standardise drugs and treatments, and by the promotion of improved life conditions for poor people around the world (Balìnska 1995). This perspective was part of a European tradition known as social medicine, which can be traced to the nineteenth century, but only in the twentieth century was it institutionalised in professorial chairs, institutes, and academic journals. Rajchman and other staff at the LNHO sought to promote the view of medical and social reform outside Western Europe, including in China, Bolivia, and Greece (Borowy 2009b). In 1937 the LNHO organised a landmark conference on rural hygiene in Bandung, Indonesia—after a proposal made by India and China—that influenced social medicine and intersectoral perspectives on the health of peasants, who made up the vast majority of the populations of low-income countries (LICs) (Brown and Fee 2008). In the years before World War II, however, Rajchman had to abandon the League of Nations, as the LNHO’s director followed a policy of appeasement of Nazi Germany and was considered a political ‘radical’. In addition to this, the League of Nations’ capacity for action was limited; although there was much hope invested in the institution, it did not have the political weight to impose its decisions and did little to oppose the Nazi invasion of Czechoslovakia in 1938 and of Poland in 1939. In the interwar period from 1919 to 1939, therefore, the two official agencies of international heath had little authority and lacked legitimacy. Rajchman´s departure was a clear example of how in critical times politics took precedence over medical priorities in international health. Another important organisation in this period was the Rockefeller Foundation, a philanthropic body founded in New York in 1913 (Barona Villar 2016). The foundation interacted with the schools of tropical medicine in Europe, especially the London and Liverpool schools in the United Kingdom, whose leaders had from their founding at the turn of the twentieth century an international—and more precisely colonial—scope and perspective. Scientific races to establish the origins and the means of transmission of the major infectious diseases that hit colonial people were part of the global narratives of both the foundation and tropical medicine in the United Kingdom and other European countries. Frequently, members of the foundation, of schools of tropical medicine, international agencies, and supporters of social medicine attended the same meetings, published in specialist journals, and worked in medical programmes in colonial and postcolonial societies, thus creating a network of expert knowledge in international health that reflected and established power relations (Neill 2012).

History of International Health   23 Unlike the OIHP or the LNHO, the Rockefeller Foundation did not represent any government; it was the first major private philanthropy focused on international health. The organisation was financed by the fortune of John D. Rockefeller’s oil company, and its medical objectives were to control hookworm disease, yellow fever, and malaria in poor countries; to control transmittable and chronic diseases in Europe; and to promote a biomedical model of training of physicians and health personnel across the globe. It was undoubtedly the most financially powerful international health organisation of the first half of the twentieth century, with the largest staff, who managed to work with flexibility and autonomy to address a very broad set of issues, ranging from supporting authoritarian public health programmes to financing the LNHO’s efforts supporting integrated health and social medicine. The Rockefeller Foundation set up five divisions, the most important being the International Health Division, which was operational from 1918 to 1951. As in the case of tropical medicine, the division worked in a context marked by the expansion of European and American imperialism, the trigger for the growth of a global market that required an international health structure that was functional for its needs. However, recent studies suggest that Rockefeller officials exhibited a greater degree of autonomy than the tropical medicine doctors (Palmer 2010). In particular, several Rockefeller field officers appear to have abandoned the priorities set in the headquarters of the foundation in New York and embraced the public health and educational goals of local communities. Moreover, the Rockefeller Foundation was a precursor of the modernisation models of development of the Cold War and of the US foreign policies of Americanisation of medical and political elites. During the nineteenth and twentieth centuries, international health organisations emerged in some regions in the world. These included the International Sanitary Council of Egypt in Alexandria and the Pan American Sanitary Bureau (PASB), established in 1902 (Cueto 2007a). The PASB—which in 1958 changed its name to the Pan American Health Organization (PAHO)—published in 1924 one of the first international treaties that recognised health as a duty of states and a right of all citizens. In 1947 former Rockefeller Foundation officer Fred L. Soper was elected as PAHO’s director, leading to a significant change in the organisation and reflecting wider changes in the institutional landscape of international health. Soper’s move from the foundation to a multilateral agency was part of a new political context that led to the rise of new bilateral and multilateral agencies. The leaders of the victorious nations of World War II rejected the possibility of restoring the League of Nations, thereby giving rise to the United Nations in 1945. During the establishment of the UN, the idea of creating specialist agencies arose, such as the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF). The latter was founded in 1946 to provide food, clothing and healthcare first to children of Europe, and later to infants of poor countries. At the same time, the Rockefeller Foundation began to lose interest in international health and focused more on technological advances in agriculture as part of a ‘green revolution’ in LICs. As a subproduct of this process, there was a migration of specialists from the Rockefeller Foundation, exemplified by Soper, to multilateral agencies.

24   Marcos Cueto

Enter the World Health Organization The new international UN agency for health, WHO, was founded in Geneva in 1948 and replaced the other European agencies (the OIHP and the LNHO), but it made an agreement with PAHO to be its regional representative in the Americas. WHO was created with a visionary perspective laid out in the founding document as part of the preamble to its 1948 constitution and is an example of the second, holistic perspective on healthcare. It affirms that health not only consists of the absence of illness but is a fundamental human right and an obligation of states (Cueto, Brown, and Fee 2011). The first director-general of WHO was the Canadian psychiatrist Brock Chisholm, who remained in the position from 1948 to 1953 (Farley 2008). During this period WHO established regional offices in Southeast Asia, Europe, the Eastern Mediterranean, the Western Pacific, and in sub-Saharan Africa (the latter only after some resistance from the imperialist nations France, Belgium, Portugal, and Britain). In regions that comprised a significant number of LICs, such as South Asia and Africa, WHO experienced in the early years an ongoing tension between centralisation and uniformity of response, according to the desires of the Geneva headquarters, and more regional power and sensitivity to local needs, which member countries pressed for. WHO assumed a number of roles, including reconstructing old health systems for prevention and treatment in European countries where they had been destroyed, as well as creating new ones in other countries where they had not previously existed, and creating a system for collecting epidemiological information. After its establishment in 1948, WHO had to work against the backdrop of the Cold War and the political rivalry between the United States and Soviet Union. The capitalist countries sought to contain Soviet expansion into new parts of the world, whilst the Moscow government intensified efforts to intervene in the internal politics of countries that were politically significant on account of their location. The result was a hardening of relations between the two superpowers. A precursor to these Cold War tensions became manifest in WHO when the Soviet Union left the agency between 1949 and 1956. The official reason given was its dissatisfaction with the work carried out by the UN and WHO. Nevertheless, the underlying reason was that the Soviets and the Americans had opposite visions of public health. The Soviets believed in a direct relationship between social and health problems. They attributed the underlying causes behind illnesses to the precarious working conditions of the population at large and to capitalist exploitation. In the Soviet Union private medical practice was prohibited, and health services were nationalised (as was the case with a number of sectors of the economy), whilst in the United States a mixed model involving private and public sector doctors and the supremacy of a network of private hospitals prevailed. In July 1955 the Soviet Union chose to return to WHO, a decision influenced by the death in 1953 of Joseph Stalin, the hard-line communist leader. The new Soviet leader,

History of International Health   25 Nikita Khrushchev, guided by the goals of ‘peaceful coexistence’ and de-Stalinisation, offered to help emergent poor nations achieve political and economic independence from European colonial powers and US economic dependency. The Soviet strategy of spreading communism as a pathway to progress led to competition between the superpowers for hegemony amongst LIC nations. The attention to these nations was elicited by the wave of decolonisation and ‘third world’ movements that emerged in countries of Africa, Asia, and elsewhere during the late 1950s and 1960s. These countries frequently had governments that were keenly aware of their new independence seeking technical assistance from multilateral organisations. It was in this context of a tense relationship in the Cold War—during the 1950s and 1960s—that WHO began to work with some autonomy. The second director-general, the Brazilian Marcolino Candau, was elected in 1953, and at this time the organisation strengthened its infrastructure and consolidated its prestige as an intergovernmental institution (Cueto and Reinalda 2015). Many WHO staff sought to show their loyalty to the agency itself, not to their own national governments, as part of the process of establishing an incipient international civil service. Legitimacy was also gained from WHO’s Assembly—its governing body of member states, which in the first years of its existence was convened in different cities around the globe—where a director-general and an executive council were elected with the responsibility of defining general directives. In addition, WHO connected experts throughout the world in specialised committees (which usually co-opted one or more members from an LIC) on a series of issues such as biological standardisation, medical education, and malaria control (some important World Health Assembly resolutions were validated by reports of these committees). These were real epistemic communities of experts who established the frontiers of ‘acceptable’ knowledge and could dismiss other proposals as at best ‘unorthodox’ and at worst simply ‘mistaken’. Another example of WHO’s growing legitimacy was the success in 1969 of the legally binding IHRs, which concentrated on cholera, plague, smallpox, and yellow fever (they were valid until 2005, when negotiations on revisions were successfully concluded) (Fidler 2001). A parallel development in the 1960s was the emergence of international health as an academic subfield, and research that concentrated on LICs. For example, in 1961 a formal programme on international health was created at Johns Hopkins School of Public Health, and seven years later it became the independent Department of International Health under the leadership of Carl Taylor. Taylor was an advisor to WHO whilst at Johns Hopkins, especially concerning community health and what became the primary healthcare (PHC) proposal of 1978, and he was the founding chair of the International Health Section of the American Public Health Association. Many consider him the founder of the academic discipline of international health in the United States, a field constructed in terms of the needs of LICs rather than relations between states, based on the assumption that industrialised nations knew what was good for the medicine and public health of both poorer nations and high-income countries (HICs) (Brown and Fee 2011). Nonetheless, for financial reasons, WHO’s independence was relative (Lee 2009). In the post-war period, the United States was the main funder of WHO and contributed more than a third of its overall budget. America maintained good relations with the

26   Marcos Cueto agency because it generally held the majority of votes in the governing health assemblies and had well-funded bilateral international health agencies. Therefore, the US government retained an important degree of independence in international health matters. Although the US State Department had had health cooperation organs since the 1940s, the most important was not established until 1961 as a unit within the US Agency for International Development (USAID). Shortly thereafter, other industrialised countries created and relied more on their own bilateral agencies, which in time concentrated more human and financial resources than multilateral agencies. The creation of these bilateral agencies made technical assistance and international health programmes an intrinsic dimension of the foreign policies of donor nations. Again, medicine and politics appeared in a new combination—which favoured the latter—in the history of international health. Candau was re-elected director-general of WHO in 1958, 1963 and 1968, and stayed in the post until 1973. In the 1950s and early 1960s, the most important global health programmes were the so-called vertical campaigns, which were clear examples of the first, technocratic perspective on international health. They generally involved actions that sought to eradicate a specific infectious disease by means of certain technologies, alongside complex administrative and financial operations. In addition, these campaigns had advantages for some HICs. In terms of national security, it was a means to protect their own territory against diseases coming from abroad. Another reason was the interest in global economic productivity: at the start of the 1950s, the United States and other industrialised nations had investments spread across the globe and were concerned about protecting the consumption of their products. The campaigns were also themselves a form of indirect subsidy to some US industries, since guidelines were laid down for the procurement of US medication and medical technology. A prominent example of this was the then widely promoted insecticide dichlorodiphenyltrichloroethane (DDT), used to control mosquitos that carried malaria. DDT was largely produced in the United States by oil companies that had found an important opportunity to sell insecticides in the malaria eradication campaign. WHO’s most important vertical campaign was carried out to address a typically rural disease: malaria, characterised by intermittent fevers that are generally not fatal but reduce the capacity for work and have a negative impact on agriculture and business. This was a clear example of the first perspective described at the beginning of this chapter—reliance on medical technology that validated international health as a contribution to global economic growth—because the justification for the elimination of malaria portrayed it as an ‘economic’ disease. In other words, disease eradication was a socio-medical intervention for the improvement of nations’ and the world’s economies. The means used were technological in the form of insecticides (DDT) and medication. In spite of some doubts about these—some reports warned of DDT not being sufficiently effective against mosquitoes, whilst medication did not always eliminate the infectious agent, Plasmodium falciparum—the 8th World Health Assembly held in Mexico in 1955 approved the eradication of malaria (Cueto 2007b). National autonomous programmes were established in almost all countries in the world. The determination to eliminate

History of International Health   27 the disease was notable for its almost limitless confidence in the power of science to overcome nature. For defenders of the programme, eradication was better than control, which sought to contain the illness by means such as drainage of wetlands and the administration of quinine to infected people. In particular, control was considered to be ineffective and, in the long term, more expensive because it required the growing use of material and human resources and significant investment in environmental health. The malaria eradication programmes—which were set to culminate after five to eight years of work—were conceived as a tool for the construction of health systems. Many WHO staff believed that the core of good health ministries was eradication programmes for major illnesses, starting with malaria. This belief went against the definition of health that was set out in the preamble to the agency’s constitution, which stated that health was not simply the absence of illness. The results of the programme were limited to a reduction in the incidence of the disease, usually in modernised areas of countries (Siddiqi 1995). The three explanations for the failure of the campaign against malaria are a decline in political will, an increase in the number of people living in endemic areas (including migrants and nomads), and the fact that mosquitoes’ resistance to insecticides was greater than had been expected. In the 1960s politicians from HICs and some multilateral agencies, such as the World Bank, thought that the main problem of poor countries was not malaria but overpopulation. According to this viewpoint, it was more important to support family-planning programmes than to fight against infectious diseases; the fight against malaria was even considered to be counterproductive because it contributed towards an increase in the population in poor countries. Family planning was first influential in private organisations, then in bilateral and finally multilateral agencies. All became convinced that decreasing population growth would have a strong impact on the capitalist economic development of poor nations. During the 1960s, bilateral foundations and agencies from highly industrialised nations began to raise concerns about the negative impacts of overpopulation and implemented birth control programmes. The first defenders of population control interventions were the International Planned Parenthood Federation, the Population Council, and the Ford Foundation, which managed to convince the US government of the importance of birth control. They argued that a high proportion of populations lived in urban areas of LICs due to high birth rates and waves of migrants from rural areas. In 1965 USAID established an office responsible for promoting population control in LICs; in the following years it grew its budget substantially and operated as a centrally managed global programme. In the same year the US president, Lyndon B. Johnson, argued that every $5 invested in population control was the equivalent of $100 invested in economic development. For subsequent presidents—Richard Nixon, Gerald Ford, and Jimmy Carter—reducing population growth was a common cause (Necochea López 2014). As a consequence, the US Food and Drug Administration (FDA) authorised the sale of contraceptive devices, including the IUD (intrauterine device), and approved the sale of contraceptive pills, and USAID became the largest bilateral organisation to donate condoms, contraceptives, and educational programmes on family planning (mostly examples

28   Marcos Cueto of the first international health perspective). One of the political justifications for implementing family planning was the fear that poor and overpopulated countries would be influenced by communism because their lack of infrastructure made providing food and jobs for an increasing number of people difficult. In this political context, LICs put into practice programmes aimed at limiting the growth of their populations, generally targeting poor women (a notable exception being India, which prioritised male sterilisation, frequently poor males, through vasectomy). At this time, Catholic country members of WHO did not consider population growth to be a problem and retained nationalist pro-birth policies. The Soviet Union and most communist countries—with the exception of China—viewed the concerns about overpopulation as a pretext by capitalist countries to obstruct the potential rise of future revolutionaries. These opponents of family planning were convinced that LICs needed more inhabitants in order to increase their economic and military potential. As an indication of the lack of consensus in WHO based on political considerations of member states, some WHO directives were against abortion, whilst others supported it along with family planning. However, those bilateral agencies and private sector organisations that supported birth control never had much confidence in the capacity of WHO to lead an international programme for family planning. Thus, in 1969 the United Nations Population Fund (UNFPA) was created, managed by the United Nations Development Programme (UNDP). In 1972, in recognition of the reach of its operations, UNFPA was placed under the responsibility of the United Nations General Assembly and given the same status as UNDP and UNICEF, a decision that created jurisdictional problems with WHO. In the 1970s WHO gave in to pressure from population control programmes of the bilateral agencies and philanthropic organisations. A factor that contributed to this change was the fact that the Soviet Union had changed its traditional pronatality policies to reduce the number of illegal abortions carried out in the country. In the early 1970s WHO set up the Special Programme of Research, Development and Research Training in Human Reproduction. However, the political landscape that supported these programmes changed once again in the 1980s, not least with the arrival of conservative governments in the United States and Europe and the rising significance of human rights and feminist groups. These groups denounced the gender, racial, and social bias of these vertical family planning programmes aimed at controlling the lives of women and the poor. They harshly criticised compulsory sterilisation in India, China, and other LICs. The Indian government offered financial compensation to individuals who underwent sterilisation, whilst the Chinese birth control programme (which promoted abortion and only allowed couples to have one child) also came under attack. Conservatives joined the criticism, questioning whether reducing population growth actually contributed to economic growth in poor nations. Consequently, US foreign policy towards population control changed dramatically, with Presidents Ronald Reagan and George H. W. Bush suspending support for family planning by international agencies. A turning point was Mexico City´s International Conference on Population in 1984, where the United States announced that recipients of bilateral aid had to agree, as a condition of receiving assistance, to neither perform, discuss,

History of International Health   29 nor promote abortion as a method of family planning. Paradoxically, all this occurred when many governments in LICs were in favour of population control and the birth rates had begun to fall in non-industrialised countries. Just as the criticisms of and debates about disease control programmes were gaining some traction and family planning programmes were experiencing problems in their implementation, the most important success in the history of international health occurred: the eradication of smallpox. This was the result of a programme developed in the 1960s and 1970s. A supporting factor was the policy of détente between the Soviet Union and the United States, with the formal aims of maintaining peace, promoting technical cooperation, and reaching a balance between the rival blocks (Reinhardt 2015). The fight against smallpox had been instigated by the Soviet Union within WHO in the early 1960s and gained further support when the American Donald Henderson, who worked at the US Centers for Disease Control and Prevention, was named programme head in Geneva. In the WHO smallpox programme, new methodologies were implemented consisting mainly of intensive surveillance and interventions focused in regions that were most affected by the disease. The campaign allowed a new generation of public health officials to cut their teeth by implementing policies that were different from the malaria eradication campaign. The most important change was the abandoning of a rigid and authoritarian plan for the health programmes and the goal of mass vaccination (or vaccinating 80 to 100 percent of the people in a given country). Instead, surveillance and containment in areas where cases were reported became the means and the goals of campaigns. These efforts led to success: by 1980 smallpox had been completely eradicated across the globe (Bhattacharya 2006); this was a major spur for applying other immunisation programmes around the world (Muraskin 1998).

The Vicissitudes of Primary Healthcare Smallpox eradication occurred in a general discussion of the new goals for international health. The discussion shaped primary healthcare (PHC), a socio-medical strategy emblematic of the second perspective described in the beginning of this chapter. PHC arose towards the end of the 1960s, at a time when the hegemony of the United States was in crisis during the Vietnam War, more African and Caribbean nations were becoming independent of European colonial rule, anti-imperialist movements on the left were organising, and the economic and political recovery of Canada and Western Europe assisted LICs in the establishment of social and public health infrastructures. PHC was influenced by a number of initiatives. First, a notable 1974 Canadian report, named after Minister of Health Marc Lalonde, outlined four factors that determined the health of a given population: biology, health services, environment, and lifestyle. Therefore, the modernisation of health services could not be divorced from other socio-medical factors. Second, social scientists who had no background in public health criticised the

30   Marcos Cueto idea that the good health of industrialised countries was the result of an increase in the number of doctors who had graduated from universities. Third, PHC was inspired by the popularity of ‘barefoot’ rural doctors in communist China, who were part of groups of health workers who lived in the communities that they served. These doctors placed greater importance on rural outreach than on urban care, carried out preventative activities, and mixed Western medicine with traditional Chinese medicine. Finally, during the early 1970s some agencies—mainly UNICEF, the UN International Labour Organization, and USAID—de-emphasised technical assistance programmes and adopted a ‘basic human needs’ approach, which prioritised integral programmes in nutrition, family planning, development of health infrastructure, and basic education in shantytowns and rural areas. These influences were important to a number of public health leaders, including the charismatic Danish doctor Halfdan Mahler, who was elected director general of WHO in 1973 (and subsequently re-elected twice, holding the post until 1988) and was a staunch supporter of PHC. The most important event for PHC was the International Conference on Primary Health Care, organised by WHO and UNICEF in September 1978 in Alma-Ata (now Almaty), then the capital of the Kazakh Soviet Socialist Republic (Cueto 2004). The conference’s final declaration included an ambitious goal: ‘Health for all by the year 2000’. The declaration contained a criticism of hospitals and overspecialised medical teams that were deemed too expensive, too sophisticated, or irrelevant for the necessities of poor people. In contrast, an ‘appropriate’ technology—meaning affordable, sustainable and directed to treating and preventing common diseases—was the alternative to meet poor people’s needs. At the same time, the installation of health posts in rural areas was prioritised over the construction of specialised hospitals. Finally, the declaration associated good health systems with social development, and work in healthcare was conceived as part of broader attempts to improve people’s life conditions. PHC was therefore positioned at the centre of the health system, and in a number of articles Mahler defended the idea that health should be an instrument of development and not simply a by-product of economic progress (Litsios 2008). One year after the PHC meeting in Alma-Ata, a new concept arose: selective primary healthcare (SPHC). Supporters of this new idea considered the Alma-Ata Declaration to be too idealistic because of its ambitious timeline and vague target of health for all by the year 2000. Instead, in 1979 the Rockefeller Foundation, leaders from bilateral agencies, and UNICEF began to work on identifying specific interventions for infant illnesses, including diarrhoea and malnutrition. Although the content and interventions of SPHC were not clear at first, in subsequent years (particularly in the first half of the 1980s) these were encapsulated in the acronym GOBI: growth monitoring, oral rehydration, breastfeeding, and immunisation. The first intervention was focused on identifying children who did not grow in line with the ideal height and weight for their age. For this, appropriate nutrition was the solution. Another was the control of diarrhoea-related diseases by means of oral rehydration therapies, known as ORT. The third sought to emphasise the nutritional and psychological importance of

History of International Health   31 breastfeeding during the child’s first months. The final intervention was immunisation, which focused on the vaccination of children to protect them from common ailments. SPHC received the full support of UNICEF, which was then run by James Grant (who had been appointed executive director of the organisation shortly after the Alma-Ata Conference). In the years that followed Alma-Ata, these two approaches to international health came to loggerheads. The first, SPHC, was supported by public health specialists who believed in a restricted rollout of PHC, placing a priority on the use of modern technology and on the leadership role of health professionals in controlling selected diseases. The second, which was approved in Alma-Ata, required cooperation between doctors and community leaders in order to construct multifunctional health posts and centres. This cooperation would also promote the improvement of the living conditions of the poor. Supporters of this second viewpoint, including Mahler, saw SPHC as a technocratic approach that was similar to vertical programmes. In addition, critics pointed out that some interventions had complications: the promotion of breastfeeding would go against the interests of powerful industries that supported artificial infant formula, and rehydration programmes were no more than a palliative for communities that had no safe water systems. The World Health Assembly tried to overcome some of these problems and approved in 1981 an International Code of Marketing of Breast-milk Substitutes that banned advertisement or promotion of these products to the public, but only a few countries implemented it effectively. One of the problems faced by the concept proposed by Mahler after Alma-Ata was that it was not clear how PHC was to be financed. Unlike other campaigns, such as the eradication of malaria in the 1950s, when funds came mainly from the United States, there were no significant resources for PHC in WHO. Another problem was that a large proportion of the medical professionals working in poor countries had an individual goal to work in specialised urban hospitals (few embraced the possibility of living in rural areas, as would be ideal under PHC). Doctors were resistant to PHC because they thought it was not based on scientific research, whilst many considered traditional medicine primitive and ineffective. As a result, PHC did not become the centre of health systems; instead most governments adopted GOBI, or some GOBI interventions such as immunisation and distribution of ORT, and turned them into vertical programmes. In the mid-1980s Mahler found himself largely isolated in Geneva in his quest to promote a broader-based PHC. In 1988 he concluded his third mandate as director-general of WHO and was replaced by the Japanese doctor Hiroshi Nakajima, who remained in the post until 1998. Japan, a country perceived by many as a rising global industrial power, enthusiastically supported Nakajima. As a result, experts expected Japan to provide the necessary financial resources to support WHO, but in the end these were not significant (Walt 1993). Furthermore, important international health conferences occurred with little participation by WHO, such as the 1994 International Conference on Population and Development that took place in Cairo, which equated gender equity and the new subfield of sexual and reproductive health.

32   Marcos Cueto

AIDS and New Epidemic Challenges Whilst PHC and SPHC were being debated, a new and unexpected disease, HIV/AIDS, altered the priorities of international agencies (see Whiteside in this volume). It was first recorded in Los Angeles in 1981 in young homosexual men with a number of op­por­tun­ is­tic illnesses that usually affected old people or those with damaged immunological systems, such as Pneumocystis carinii fungus and Kaposi’s sarcoma (Fee and Fox 1988). Not long afterward, cases were recorded amongst haemophiliacs—who were dependent on blood transfusions—and injection drug users. In the early years, stigmatising names emerged, such as the 4-H disease because it seemed to affect Haitians, homosexuals, haemophiliacs, and heroin users. The acronym GRID (gay-related immune deficiency) reinforced the stigma. Once it had been determined that the disease was not limited to the homosexual community, discriminatory terms were replaced by the acronym AIDS (acquired immunodeficiency syndrome). Initially it was perceived as a disease of rich countries, but by the mid-1980s it was clear that it was spread all over the world. WHO was initially slow to respond to AIDS. The first director of the Global Program for AIDS, created only in 1987, was the American doctor Jonathan Mann, under whom it became WHO’s largest programme for addressing a single disease. For perhaps the first time, medical investigations and public health interventions were put into practice alongside human rights promotion, allowing a disease to be addressed concomitantly from scientific, clinical, and political perspectives. Mann chided stigma and discrimination and promoted confidential testing and educational programmes as well as the use of condoms as broad strategies for prevention (Fee and Parry 2008). The AIDS programme promoted a greater cultural awareness and tolerance of sexual minorities and was closer to the second socio-medical perspective described in this chapter, because it placed emphasis on the social and cultural context of ill people and their partners and families. Mann´s firm stand on international health helped to raise funds and make the disease—and indirectly international health—a priority of ministers of finance and presidents. However, Mann came into conflict with the director-general of WHO, Nakajima, who did not agree with the programme’s scope, leading to the former resigning from his position and moving to the United States. Sadly, he died in an airplane accident in 1998 on his way to a meeting of the recently established Joint United Nations Programme on HIV/AIDS (UNAIDS), an agency directed by the Belgian doctor Peter Piot, that brought together ten organisations of the UN system. UNAIDS became the main driver for global action against AIDS and took over the leadership role from WHO in its fight against HIV/AIDS. In the wake of AIDS, during the final decade of the twentieth century outbreaks of old and new bacterial, viral, and parasitical diseases occurred in unexpected places. Examples include diphtheria in Russia in 1990, cholera in Peru in 1991, yellow fever in Kenya in 1992, and bubonic plague in India in 1994, as well as dengue epidemics in Latin America in 1996 and 1997. Scientists created two terms for the new epidemiological situation: emerging and re-emerging diseases. Both could appear in any part of the world

History of International Health   33 and spread rapidly to another part because of the ease of movement of people, goods, animals, and food. These terms were both a harbinger of, and contributed to, the discursive shift from ‘international’ to ‘global health’. Although there was no precise definition for an emerging disease, it was considered one whose microbiological cause or clinical manifestation appeared amongst humans for the first time. The term re-emerging was attributed to contagious diseases that reappeared in a geographic area after a period of prolonged absence. Both types of disease were the unpredictable result of climate change and increased national, regional, and international mobility and migration (which produced greater contact between populations that had previously been more isolated). Most studies agreed that there were social causes for this, including the collapse of public health infrastructure both in LICs (much of which was occasioned by the World Bank’s structural adjustment policies linked to development loans; see Schrecker in this volume) and in countries from the former Soviet bloc, where the transition of socialist economies and health infrastructures to market systems proved difficult and created unstable societies with people vulnerable to disease. Alongside these emerging and re-emerging diseases, new transnational non-­ governmental organisations (NGOs) acquired greater relevance, along with patient groups that made demands including access to treatment and drugs (especially groups of people living with HIV and AIDS; see Whiteside in this volume), thereby increasing the number of actors in international health. Amongst the new actors, one of the most important was the French Médecins sans Frontières (MSF, or Doctors without Borders). This was a network of physicians, initially founded in 1971, whose work focused on providing medical assistance to refugees and populations affected by epidemics and was awarded the Nobel Peace Prize in 1999. MSF blazed the trail for other international non-profit organisations like Partners in Health, created in 1987 in Boston. During this period, WHO was perceived as a troubled agency incapable of responding rapidly to new epidemiological challenges. Neo-liberal governments criticised multilateral agencies, portraying them as troubled, bloated, and inefficient bureaucracies that reflected the realities of the Cold War era, which had ended in 1990, and were incapable of carrying out internal reform. WHO’s leadership in international health was also waning in light of the changes caused by the transnationalisation of finance and the aggressive activities of other international organisations, particularly the World Bank, which since 1979 had an active Population, Health and Nutrition Department. The health policies of the World Bank, which were consistent with neo-liberal economic policies (see Schrecker in this volume), became a dominant force in international health soon after the report entitled Investing in Health (1993). Importantly, by the 1990s the World Bank budget for international health was greater than the total budget of WHO (Ruger 2005). Moreover, the autonomy of the main multilateral health agency was at risk: the World Health Assembly did not control about two-thirds of the money WHO spent because of the magnitude of donations that were ring-fenced by member states for specific programmes. At this same time, some experts began to argue that the new term global health should replace the term international health because health problems were transnational and should be resolved by means of supranational measures through a

34   Marcos Cueto collection of public and private partners (Brown, Cueto, and Fee 2006). Initially, the role of WHO was not clear in this new framework of ‘global’ health. Thus, WHO began to lose its leadership position on the international stage (although this was partially reversed with the appointment of a new director-general, Gro Harlem Brundtland, in 1998, a trained physician who had spent most of her life as a leading politician in her home country, Norway, and as a leader of environmental causes in the world.

Conclusion Change in international health frequently was precipitated not so much by new biomedical or public health innovation as by changes to the global political order, such as the expansion and intensification of empires, migration, trade routes, and maritime commerce; the legacies of the two world wars; the surge and crisis of the Cold War; the growing pressure for independence and decolonisation; and neo-liberalism. Medical reactions to these developments included tropical medicine, medical philanthropy, social medicine, PHC, and SPHC. Thus, the history of international health cannot be divorced from broader political, economic, and social events. Nevertheless, the first accords and international health organisations left important legacies, such as a degree of cooperation between commercial and medical interests, the construction of an epidemiological network of experts around the world. and the IHRs. During the twentieth century, agencies did not limit themselves to communicating and controlling the damage caused by epidemic outbreaks, but oscillated between two socio-medical perspectives that had political connotations. One was to promote medical and social reforms to change the life conditions that led to epidemics (as defended by the LNHO and stated in WHO’s Constitution Preamble of 1948). In a similar vein, the original concept of PHC was shaped. A different perspective was to conceive international health as a tool to protect local, national, and global economies, under the assumption that the health of populations was a by-product of economic growth (as did the arguments to validate the malaria eradication programme of the 1950s). The debate, tension, and accommodation of these two socio-medical perspectives, however, would persist into the twenty-first century. Underlining their history helps to illuminate daunting contemporary problems of international health: fragmentation, discontinuity, and problematic governance (Lidén 2014).

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History of International Health   35 Bhattacharya, Sanjoy. 2006. Expunging Variola: The Control and Eradication of Smallpox in India, 1947–1977. New Delhi: Orient Longman. Birn, Ann Emanuelle. 2009. ‘The Stages of International (Global) Health: Histories of Success or Successes of History?’ Global Public Health 4 (1): 50–68. Black, Maggie. 1996. Children First: The Story of UNICEF, Past and Present. Oxford: Oxford University Press. Borowy, Iris, 2009a. Coming to Terms with World Health: The League of Nations Health Organization, 1921–1946. Frankfurt am Main, Germany: Peter Lang. Borowy, Iris. 2009b. Uneasy Encounters: The Politics of Medicine and Health in China, 1900–1937. Frankfurt am Main, Germany: Peter Lang. Brown, Theodore M., and Elizabeth Fee. 2008. ‘The Bandoeng Conference of 1937: A Milestone in Health and Development.’ American Journal of Public Health 98 (1): 42–43. Brown, Theodore M., and Elizabeth Fee. 2011. ‘Carl E. Taylor (1916–2010): A Beloved Pioneer in International Health.’ American Journal of Public Health 101 (7): 1216. Brown, Theodore M., Marcos Cueto, and Elizabeth Fee. 2006. ‘The World Health Organization and the Transition from “International” to “Global” Public Health.’ American Journal of Public Health 96 (1): 62–72. Cueto, Marcos. 2004. ‘The Origins of Primary Health Care and Selective Primary Health Care.’ American Journal of Public Health 94 (11): 1864–1874. Cueto, Marcos. 2007a. The Value of Health: A History of the Pan American Health Organization. Rochester, NY: University of Rochester Press. Cueto, Marcos. 2007b. Cold War, Deadly Fevers: Malaria Eradication in Mexico, 1955–1975. Baltimore, MD: Johns Hopkins University Press. Cueto, Marcos, Theodore Brown, and Elizabeth Fee. 2011 ‘El proceso de creación de la Organización Mundial de la Salud y la Guerra Fría.’ Apuntes: Revista de Ciencias Sociales 38 (69): 129–156. Cueto, Marcos, and Bob Reinalda. 2015. ‘Candau, Marcolino Gomes.’ In IO BIO: Biographical Dictionary of Secretaries-General of International Organizations, edited by Bob Reinalda, Kent J. Kille, and Jaci Eisenberg. www.ru.nl/fm/iobio. Echenberg, Myron J. 2007. Plague Ports: The Global Urban Impact of Bubonic Plague, 1894–1901. New York: New York University Press. Espinosa, Mariola. 2009. Epidemic Invasions: Yellow Fever and the Limits of Cuban Independence, 1878–1930. Chicago: University of Chicago Press. Farley, John. 2004. To Cast Out Disease: A History of the International Health Division of the Rockefeller Foundation (1913–1951). Oxford: Oxford University Press. Farley, John. 2008. Brock Chisholm, the World Health Organization, and the Cold War. Vancouver: University of British Columbia Press. Fee, Elizabeth, and Daniel M. Fox, eds. 1988. AIDS: The Burdens of History. Berkeley: University of California Press. Fee, Elizabeth, and Marion Parry. 2008. ‘Jonathan Mann, HIV/AIDS, and Human Rights.’ Journal of Public Health Policy 29 (1): 54–71. Fidler, David P. 2001 ‘The Globalization of Public Health: The First 100 Years of International Health Diplomacy.’ Bulletin of the World Health Organization 79 (9): 842–849. Hardy, Ann. 1993 ‘Cholera, Quarantine and the English Preventive System, 1850–1895.’ Medical History 37 (3): 250–269. Harrison, Mark. 2012. Contagion: How Commerce Has Spread Disease. New Haven, CT: Yale University Press.

36   Marcos Cueto Howard-Jones, Norman. 1975. The Scientific Background of the International Sanitary Conferences, 1851–1938. Geneva: World Health Organization. Lidén, J. 2014. ‘The World Health Organization and Global Health Governance: Post 1990.’ Public Health 128 (2): 141–147. Lee, Kelley. 2009 World Health Organization (WHO). London: Routledge. Litsios, Socrates. 2008. The Third Ten Years of the World Health Organization, 1968–1977. Geneva: World Health Organization. Muraskin, William. 1998. The Politics of International Health: The Children’s Vaccine Initiative and the Struggle to Develop Vaccines for the Third World. Albany: State University of New York Press. Necochea López, Raúl. 2014. A History of Family Planning in Twentieth-Century Peru. Chapel Hill: University of North Carolina Press. Neill, Deborah J. 2012. Networks in Tropical Medicine: Internationalism, Colonialism, and the Rise of a Medical Specialty, 1890–1930. Stanford, CA: Stanford University Press. Packard, Randall  M. 2016. A History of Global Health: Interventions into the Lives of Other Peoples. Baltimore, MD: Johns Hopkins University Press. Paillete, Céline. 2014. ‘Diplomatie et globalisation des enjeux sanitaires: Camille Barrère, un itinéraire diplomatique du Caire à l’Office international d’hygiène publique (1883–1926).’ Hypothèses 17: 129–138. Palmer, Steven. 2010. Launching Global Health: The Caribbean Odyssey of the Rockefeller Foundation. Ann Arbor: University of Michigan Press. Reinhardt, Bob H. 2015. The End of a Global Pox: America and the Eradication of Smallpox in the Cold War Era. Chapel Hill: University of North Carolina Press. Ruger, J. P. 2005. ‘The Changing Role of the World Bank in Global Health.’ American Journal of Public Health 95 (1): 60–67. Siddiqi, Javed. 1995. World Health and World Politics: The World Health Organization and the UN System. Columbia: University of South Carolina Press. Stern, Alexandra, and Howard Merkel. 2004. ‘International Efforts to Control Infectious Diseases, 1851 to the Present.’ Journal of the American Medical Association 292 (12): 1474–1479. Walt, Gill. 1993. ‘WHO under Stress: Implications for Health Policy.’ Health Policy 24 (2): 125–144. Watts, Sheldon. 1997. Epidemics and History: Disease, Power, and Imperialism. New Haven, CT: Yale University Press.

chapter 3

Gl oba lisation a n d the Politics of Gl oba l H e a lth Matthew Sparke

Globalisation is widely understood as a name for processes of global political-­ economic integration. But it also operates on an ideational level as a key term in political discourse about the governmental norms and ideals of integration. Approaching ­globalisation with such a two-level definition contributes to debates over how its framing influences come together with its material interdependencies to shape global health politics (Benatar 2016; McInnes et al. 2014; Ng and Ruger 2011). Conventionally, when politics concerns global public health security, it is tied to just the integrative aspects of globalisation, such as trade and travel, through an epidemiological concern with globalising disease outbreaks. By contrast, when global health politics concerns efforts to extend drug access and health services to the world’s poor, it is tied to ideational globalisation through a humanitarian concern with globalising human health rights. But attuned to how globalisation has led to the merger of public health prevention and biomedical intervention under the title of global health, this chapter argues that the resulting politics also reflects the policies and practises that tie together globalisation’s own integrative and ideational imperatives. These are the pro-market policies and practises of neo-liberalism. Inspired and informed by the growing interdisciplinary literature on the impact of neo-liberalism on health and health policies, the argument presented here is that understanding how globalisation has shaped the politics of global health therefore also demands close attention to the dictates and determinants of neo-liberalisation (Farmer et al. 2013; Glasgow and Schrecker 2015; Keshavjee 2014; Kim et al. 2000; Labonté and Stuckler 2016; Navarro 2007; Rowden 2009; Rushton and Williams 2012). Rather than invoke ‘neo-liberal globalisation’ as an ahistorical political idea, the theoretical approach taken in what follows is to treat both globalisation and neo-­ liberalisation as ongoing processes that continue to co-evolve through both material

38   Matthew Sparke and ideational iterations that influence one another (Sparke 2013). Put another way, this means coming to terms with neo-liberalism as a thread of policy and practise that capitalist globalisation has spun and braided but by which it has also been bound and led. As well as challenging the dualism dividing political economy from political-­cultural analysis, this approach makes it possible to go beyond the conventional dualistic depiction of public health security and international health intervention as simply merging together to form global health as a result of globalisation. Instead, by highlighting how globalisation’s own integrative and ideational imperatives have been bound together by neo-liberalisation, the chapter focuses on how the associated norms and practises of pro-market governance have come to structure global health. This helps answer calls for more critical reflexivity about the normative implications of dominant global health governance definitions and metaphors (Bozorgmehr 2010; Lee and Kamradt-Scott 2014; Stuckler and McKee 2008). But by also highlighting how other non-neo-liberal traditions of global health have thereby been repressed, it suggests that the politics of neo-liberalisation and its discontents keep returning to haunt global health like contentious ‘ghosts in the machine’ (Bruen and Brugha 2014). Their contestability and normativity notwithstanding, definitions of global health that depict it as a merger of just two traditions remain a useful entry point into global health politics. On the one side of this dualism lie depictions of a regime of global health security with origins in traditions of national public health surveillance, disease prevention, and precautionary regulation. On the other side of the dualism are accounts of a regime of global biomedical humanitarianism with origins in traditions of international intervention, tropical medicine, and disease-specific treatment programmes. The first section of this chapter reviews how global health tends to be defined by narratives describing the merger of these two regimes. After introducing the two-level definition of globalisation, it further underlines how such depictions of a globalised convergence of the two regimes need to be supplemented to accommodate the intersecting influences of neo-liberalisation and its discontents. The second section of the chapter outlines the politics of neo-liberal conditionality and austerity in which postcolonial visions of global health universality were subordinated to selectivity. It begins with the damaging impacts of Washington Consensus neo-liberalism on health systems and health outcomes globally. This neo-liberal consensus characteristically came with arguments that ‘wealthier is healthier’. However, in response to the debt crises of the 1980s, the World Bank, International Monetary Fund (IMF), and associated economic elites enforced neo-liberalisation with structural adjustment programmes (SAPs) that systematically undermined health and health systems. In rich and poor countries alike, globalisation has further shrunk the policy space available to governments pursuing health equity, either by unleashing competitive market pressures that undermine wages, social protections, and the tax base needed to fund social programmes, or by providing ideational alibis for further neo-liberalisation. Compounded by more recent rounds of austerity, as well as rising in-country inequalities, fraying social safety nets, and health-worker brain-drain dynamics, the results have included the

Globalisation and the Politics of Global Health   39 widespread embodiment of neo-liberalism in increased disease vulnerability, suffering, and premature death (Sparke 2017). Responding to the damaging health consequences of Washington Consensus neoliberalism, global health initiatives have developed a form of compensatory market-­ justice care regime co-funded and co-led by global health philanthropy (see Youde in this volume). The resulting investments have been impressive and have saved millions of lives. But they have also doubled down on selectivity both spatially and in terms of ­targeting particular diseases. Instead of ‘Health for All’, the resulting politics of enfranchisement with meaningful rights to health and well-being remains extremely patchy. To explain this patchy politics of global health selectivity, the third section of the chapter argues that today’s global health initiatives are influenced by a ‘New Washington Consensus’ premised on the financialised idea that funding for health leads to wealth (Mitchell and Sparke 2016). The resulting ‘healthier is wealthier’ reversal of the old Washington Consensus represents a new ‘common sense’ (itself just as questionable and contested as the old ‘wealthier is healthier’ framing) in which the macro-market failures of neo-liberalisation under globalisation are often acknowledged, and yet for which new micro-market experiments in global health investment are being developed by public-private-philanthropic partnerships as compensatory but still, in many marketmediated ways, neo-liberal responses (Kenny 2017; McGoey, Reiss, and Wahlberg 2011; McGoey 2015; Ruckert and Labonté 2014; Thomas and Weber 2004). The investment logics of today’s global health initiatives may have enabled their expansion in the context of neo-liberal globalisation, but it now puts them in especial jeopardy amidst rising antiglobalism. Writing in the midst of Donald Trump’s electoral triumph, Richard Horton, the editor of the Lancet, saw it as ‘a moment of emergency in the idea of the global’ (Horton 2016). For Trump and his supporters, conversely, the emergency is instead often imagined in the inverted terms of global threats that licence authoritarian nationalism and reactionary dissent (Bessner and Sparke 2017). Whether it is the idea of the global in global climate change, global trade, global migration, or global health itself, Trump disputes or disparages the policies and people involved, depicting them all as threats to American sovereignty. The chapter therefore concludes with some reflections on what this reactionary brand of Washington Dissensus might mean for the future of global health.

Globalisation and the Neo-liberal Merger of Global Health’s ‘Regimes’ To begin with, let us consider how a doubled definition of globalisation that addresses both its integrative and its ideational elements offers a way of coming to terms with how its invocation can normalise neo-liberal policymaking. Most obviously, this is useful as a way of explaining how such ideational framing pre-empts policies that might mitigate

40   Matthew Sparke the health-damaging downsides of global economic integration and competition (Rushton and Williams 2012). ‘Taming the inequality machine’, to use Ted Schrecker’s critical formulation, is so much harder when health policies that might be introduced as counter-measures are pre-emptively contested as being costly drags on growth and competitiveness in the context of globalisation (Schrecker 2016). And even when it is not invoked as an alibi for inaction on the social determinants of ill-health, the ideational influence of globalisation discourse can work affirmatively alongside the material market pressures of global competition to construct how the ‘global’ assumed in global health frames policy (Legge 2016). Global scarcity is often assumed in this way as necessitating global health priority-setting and cost-effectiveness studies in order to create narrowed targets for global health investment (e.g., Jamison et al. 2013). By highlighting the way such arguments involve distinctly neo-liberal assumptions about how to manage increasing global interdependency and governmental convergence, a two-level definition of globalisation can contribute to the wider work of revealing the resulting exclusions (Chiriboga et al. 2015). To develop the doubled definition requires adding an extra critical step beyond the ‘three-step’ approach normally taken in introductory academic texts on globalisation (following the model of Held et al. 1999). Conventionally these ‘three-step’ accounts seek to move through the contested terrain of globalisation’s political meanings by eschewing all the myth-making about it being a new, inevitable, and flattening juggernaut of political-economic change. Thus their first step is to argue that hyper-globalisation myths exaggerate when they lead to depictions of a smooth, hypercompetitive, borderless world of market-based integration. Second, they nevertheless also argue that sceptics who maintain that nation-states remain the fundamental political units of international relations and political-economic governance fail to acknowledge the real transformations that globalisation involves. And so third, the three-step accounts suggest it is best to follow their own ‘transformationalist’ approach to globalisation, acknowledging growing global integration and global governance, but also offering evidence-based assessments of how the transnational ties vary in their transformational impacts based on varied national, local, and historical factors. This measured transformationalist approach remains an important analytical guide, but it overlooks what is at stake politically in the divide between the hyper-globalists and the sceptics: namely, neo-liberalisation (Sparke 2013). Typically it is the normativity and advisability of pro-market policymaking that hyper-globalists hype and sceptics scorn. Hyper-globalists tend to argue for the inevitability of market-led neo-liberalisation in order to justify more pro-market adjustments. By contrast, sceptics maintain claims about national sovereignty and political autonomy in order to protect public and personal spaces for imagining alternative ways of managing the integrative imperatives of globalisation. Reading accounts of globalisation this way means taking care to notice how empirical claims about the integrative effects of globalisation often become bound up with normative political claims about ‘Globalisation’ and synonyms such as the ‘Global Market’ (Steger, 2005). It also invites an ongoing openness to alternative global imaginaries and political responses—including the

Globalisation and the Politics of Global Health   41 ‘global turn’ of postcolonial politics organised out of the global South—that have been forgotten or marginalised as a result (Darian-Smith and McCarty 2017). In global health the pro-market normativity of globalisation discourse and the resulting exclusions and elisions have already been widely critiqued (Fort, Mercer, and Gish 2004; Kim et al. 2000; Navarro 2007; Rowden 2009). Rather than naturalising neoliberalism, this critical work argues that the pro-market policies and practises instead tend to be coerced and contested. The resulting recriminations from the world’s poor have further led many critics to suggest that neo-liberalisation is spreading both globally and damagingly like a plague (Schrecker and Bambra 2015; Farmer 2004; Keshavjee 2014). When the resulting ill-health outcomes are reframed by neo-liberal norms as personal responsibilities tied to individual behaviours, the associated tendency towards selfblame has further been critiqued as constituting a secondary health burden or ‘double burden’ of neo-liberalism (Glasgow and Schrecker 2015). For all these critical reasons, globally inclusive, ethical appeals to reimagining global health as ‘global’ in the sense of universally available for all are often explicitly anti-neo-liberal (e.g., Farmer et al. 2013). And even when they do not dwell on the word neo-liberalism itself, critical accounts underline that the word global in global health falls prey to ‘misuse’ or to being a ‘misnomer’ when not made accountable to the non-neo-liberal work of extending ‘health for all, by all, and in all’ (Garay, Harris, and Walsh 2013; Heywood 2002). Avoiding the dangers of misuse and misnomers clearly therefore demands more attention to the complexity and contestation involved in the globalisation of preceding regimes in global health (Brown et al. 2006). What the attention to globalisation as both integration and ideation offers in this regard is a prompt to investigate how definitions depicting global health’s globalisation can frame out as much as they frame in, even when they explicitly announce an interest in global health equity. Take for example the authoritative definition published in the Lancet in 2009. ‘Global health’, it explains simply and clearly, ‘is derived from public health and international health’ (Koplan et al. 2009). The authors thereby aver that ‘global health encompasses prevention, treatment and care’ in a ‘truly interdisciplinary sphere’ that ‘places a priority on improving health and achieving equity in health for all people worldwide’ through ‘a synthesis of population-based prevention with individual-level clinical care’ (Koplan et al. 2009, 1995). Due to globalisation, they suggest that the two traditions are being bridged by all sorts of new multidisciplinary and interdisciplinary engagement, including more two-way flows of experience and expertise ‘between developed and developing countries’ (Koplan et al. 2009, 1995). Amidst all this global inclusivity, however, the alternative health equity tradition of primary healthcare (PHC) disappears from the definition of global health altogether. Such authoritative definitions of the field are themselves political interventions, inspired at least in part by fund-raising goals. The ways they link the ‘low politics’ of delivering global health humanitarianism with appeals to the ‘high politics’ of health security and national security are often tied thus to strategic bids to secure government budget allocations for global health. As Horton has summarised in the Lancet: ‘The unfortunate reality is that humanitarian arguments alone often fail to win the support of

42   Matthew Sparke politicians. Security arguments change the terms of the political debate’ (Horton 2017). These sorts of strategic ties to security discourse by advocates of humanitarian biomedicine have a proven history in securing funding in the West and are now also evolving in complex new ways with the rise of BRICs (Brazil, Russia, India, and China) as emerging economies (Gómez 2018). But however strategic they may be, global health merger appeals tend also to gloss over huge ongoing political-economic asymmetries in NorthSouth relations that postcolonial advocates of PHC had once hoped to overcome. The same globalist gloss also in turn elides the many ways in which global health partnerships are aligned with the geopolitical management of enduring North-South inequalities (Herrick, 2017). This is where globalisation as ideation plays a role in obscuring the inequalities and tensions structuring globalisation as integration. Focused more on the differences between the traditions, the anthropologist Andrew Lakoff has instead argued that the juxtaposition of the ‘two regimes of global health’ highlights ‘some of the tensions inherent in many contemporary global health initiatives’ (Lakoff 2010, 59). The ‘global’ in global health appears far less unifying and inclusive in this account. Instead Lakoff suggests that these differences can lead to political contradictions rather than just new funding for universities and treatment programmes. His main example is the controversy surrounding Indonesia’s demands in 2007–2008 for access to vaccines in return for sharing flu virus samples with the WHO. From the global health security perspective, the Indonesian health minister’s refusal to share samples without a promise of vaccine access was easily politicised as an affront to global public health surveillance. But, Lakoff underlines, from the side of global humanitarian biomedicine, Indonesia’s demands for equitable access to vaccines was tied closely to health citizenship rights. He ends his essay after reviewing several other aspects of the emerging global health security regime by suggesting that its evolving relationship with global health humanitarianism might well be far more asymmetrical and parasitical than the symmetrical and equitable synthesis suggested by Koplan and colleagues. Given this politics, Lakoff concludes with a much more dystopian depiction of global health expertise exchanges in which ‘humanitarian biomedicine could be seen as offering a philanthropic palliative to nation-states lacking public health infrastructure in exchange for the rights of international health organisation to monitor their populations for outbreaks that might threaten wealthy nations’ (Lakoff 2010, 75). Lakoff ’s politically provocative reframing of a fundamentally unequal global health trade-off between, on the one hand, public health security protections for the wealthy, and on the other, palliative care for the poor, aligns with other studies pointing to how populations in the global South can thereby be turned into canaries in the cloudy mine shafts of global health securitisation (e.g., Lowe 2010; Sparke and Anguelov 2012). Such critiques of data mining through global health surveillance are further buttressed by literatures addressing other globalising processes of ‘bioprospecting’, ‘biocoloniality’, and intellectual property extraction from the hinterlands of global health (e.g., Crane 2013; Rajan 2006; Schwartz-Marín and Restrepo 2013). But as Simon Reid-Henry has highlighted, Lakoff ’s reduction of global health’s heterogeneity to just two political regimes itself remains a simplification (Reid-Henry 2016). For the same reason, his depiction of

Globalisation and the Politics of Global Health   43 a simple hierarchy of interests shaping the global ties between each regime also begs a series of questions about the political-economic histories and structures that have elided other regimes and led to today’s global asymmetries. What accounts for the absence of universal PHC from the simple depiction of just two regimes? What were the politicaleconomic processes that came to subordinate the goals of world health universality to global health selectivity? And what kinds of global health subcitizenship are emerging as a result of such palliative pay-offs from the ‘high politics’ world of global health security to the ‘low politics’ targets of humanitarian biomedicine? The common thread running through answers to these questions is neo-liberalisation. In the next section we address the issue of the elided alternatives by considering the global regime of ‘Health for All’ that was imagined and planned at Alma-Ata. Then in the following sections we turn to how this health universalisation vision was subsequently eclipsed in the 1980s and then replaced in the new millennium amidst the ­spiralling political-economic conditioning and pro-market ideological influence of neo-liberal globalisation.

Alma-Ata and Postcolonial World Health Universalisation When universal PHC plans are excluded from simple merger narratives of global health, a great deal of global history and global struggle is elided. Just as hype-bound market metanarratives about globalisation tend to marginalise alter-globalisation solidarity across global civil society, and just as they also ignore other globe-spanning ties of science and anti-imperial revolt, dominant derivations of global health obscure the postcolonial politics and legacies of social medicine that led to the promotion of universal PHC. Such framing both reflects and reinforces neo-liberal policymaking that overlooks the possibility of developing universal PHC systems, ignoring their many benefits in terms of delivering sustainable improvements in health outcomes and health equity (Rao and Pilot 2014). In contrast, by remembering the colonial turned postcolonial backstory of globalisation, we can bring back into view what neo-liberal narratives of globalised global health elide. Colonial medicine had systematically tended to privilege the health of administrators, settlers, and colonial armies over the health of local populations, albeit with exceptions for locals when they were economically useful as workers in colonial mines, plantations, and infrastructure projects, or when their ill-health threatened the colonial project itself (Packard 2016). So when postcolonial governments sought to replace the racist hierarchies of colonial control and care, they also sought to extend health rights to the citizens of their newly independent countries. Historically and geographically this was a context-conditioned process, influenced by the regional legacies of imperialism, including sometimes the training of local public health officials

44   Matthew Sparke in tropical medicine and sanitation strategies (Anderson 2006; Packard 2016). Despite the resulting diversity of experiences, though, universalising health rights became a common postcolonial goal globally. After World War II, postcolonial concerns combined with post-war initiatives in human rights internationalism to shape the global politics in which the constitution for the World Health Organization (WHO) was drafted. As a result, its preamble famously asserted that health was a fundamental human right, that it incorporated ‘complete physical, mental, and social well-being and not merely the absence of disease or infirmity’, and that it was the responsibility of governments to protect this comprehensive kind of health citizenship ‘through the provision of adequate health and social meas­ures’ (Packard 2016, 89). As Randall Packard details in his history of global health, these ideals were themselves inspired in part by a Depression-era tradition of social medicine that had informed the Bandoeng Conference of 1937 in Java. As such, they also reflected a basic interest in inclusive health equity and justice coming from the colonised parts of the world. In 1946, amidst all the post-war and postcolonial hopes for rebuilding and improving social welfare globally, the WHO constitution therefore came to affirm health citizenship in its broadest socialised sense. However, amidst the growing conservativism of the 1950s, the Cold War, and US commitments to free market development, the underfunded WHO returned to the technical, top-down, disease-specific approach to international health advocated by its dominant donors: chiefly the US government and the Rockefeller Foundation (see Cueto in this volume). With the Declaration of Alma-Ata in 1978, the pendulum of policy swung back radically (but briefly) in the direction of postcolonial health equity and universality. Three thousand delegates from 134 countries attended, and the consensus reached after seven days of deliberation reaffirmed WHO’s founding definition of health, health rights, and  associated government health responsibilities (Cueto 2004). This radical rethink resulted from numerous intersecting influences, including the leadership of WHO director Halfdan Mahler. But arguments from postcolonial countries tied to the non-aligned movement and the G77 were key, including both their demands for a new international economic order (NIEO) and their critiques of the failings of Western-dominated development (Thomas and Weber 2004). Instead of the diseasespecific biomedical campaigns associated with such development, there was great interest in the new model of PHC already being planned in countries such as Costa Rica, Mozambique, Tanzania, China, and Cuba. Using community health workers, examples of successful PHC also suggested that improvements in health outcomes could best be sustained by commitments to social and economic welfare. These were the ideals that were then encoded in the ten-point declaration that came out of Alma-Ata, albeit without any detailed guidelines about implementation in particular country contexts, and also without any global funding. Packard suggests that these drawbacks help explain why the health universality idealised at Alma-Ata was so swiftly subordinated to top-down, disease-specific selectivity afterwards. He also suggests that the lessons drawn from the success of smallpox eradication (and the failure of WHO’s malaria eradication efforts) played a role too. However, he and many others

Globalisation and the Politics of Global Health   45 argue that another, much more global obstacle to realising the health universalisation vision articulated at Alma-Ata was the changing political-economic environment of globalising capitalism (Farmer et al. 2013). It is to the role played by these global market forces and norms that we now turn.

The Washington Consensus and the Conditionalisation of Global Health At the same time that ‘Health for All’ was being imagined as an international health goal at Alma-Ata in 1978, the material integration effects of the global economy were already creating crisis conditions that would make the realisation of the declaration impossible. The global interconnections of this perfect political-economic storm have been described at length elsewhere, including the ways in which they tied together growing global overcapacity in manufacturing, increasing global competition for overseas markets, declining global profit rates, decreasing global valuations of the US dollar, increasing global cartel consolidation (such as OPEC), and the resulting globalisation of inflation (Sparke 2013). By the end of the 1970s these developments had led to an increasingly globalised problem of economic stagnation combined with inflation, or ‘stagflation’. In the United States, the policy response came finally in 1981 when the Federal Reserve (influenced by the neo-liberal ideas of Chicago School economists) dramatically increased interest rates. This created a further slowing in global economic growth as the costs of borrowing went up. It also led to a rapid rise in the value of the dollar. The result was a recession in the United States and other wealthier countries, but in poorer countries around the world the outcomes were widely catastrophic. The global slowdown diminished demand for their exports of raw materials. At the same time, the debts that they had built up in the 1970s suddenly became much harder to manage. Denominated in the newly expensive dollars, with interest rates pegged to the increased interest rates in the United States, the loans could no longer be serviced. Default became the only option. In the midst of the ensuing debt crises, the IMF and World Bank stepped in to stabilise the global financial system by restructuring the loans and paying off the commercial banks and their lenders. It was in the aftermath of these crises that the language of globalisation grew in ­popularity. This reflected an increasing awareness of the underlying global market interconnections and the increased appeals being made to the ideals of market integration and competition by the policymakers seeking to manage the crises. The neo-liberal policies of the Washington Consensus were spun into a thread that bound and led global development, thereby making globalisation synonymous with neo-liberalisation. John Williamson (1990), who coined the term Washington Consensus to describe this vision of neo-liberal globalisation, saw it as a consensus amongst DC-based economists (chiefly at the World Bank, IMF, and US Treasury) on the main policies that poor countries

46   Matthew Sparke should pursue in order to recover and develop amidst increasing global market integration. Trade liberalisation, privatisation, business deregulation, financial deregulation, reduced taxation, and diverse forms of public sector austerity were promoted as how countries should adjust to global market forces and restore stability to the global financial system. These policies were then packaged by the IMF and World Bank and imposed on the countries caught up in the debt crises in the form of SAPs. Whilst the ideals of market-led development were what provided the ideational structure of SAPs, the reasons they could be enforced were tied to the material interdependencies of the markets. In short, when the indebted countries defaulted on their debts to private banks, they had no lenders to turn to except the World Bank and IMF. These two DC-based international financial institutions stepped in principally to protect the interests of the banks and wealthy lending countries. However, they also used their power as lenders of last resort to insist on the Washington Consensus reforms enumerated in SAPs. Also known as ‘conditionalities’, these neo-liberal reforms were what then turned the ideational entwining of neo-liberalisation and globalisation in the Washington Consensus into a powerful conditioning influence on global health (Farmer 2015). SAPs affected health outcomes through a wide range of causal mechanisms that were both direct and indirect. Directly, SAP conditionalities had immediate negative impacts due to budget cutbacks on health spending, education, and other forms of social protection. As well as imposing user fees for health services, they also imposed pay ceilings for public sector employees such as health workers. These direct influences alone were enough to make the government responsibilities for health declared at Alma-Ata impossible to honour. But the indirect influences went much further in undermining the promise of ‘Health for All’ by unleashing global market competition and enabling market rule. Capsizing the commitment made to health as a fundamental human right, advocates of structural adjustment tended to take a market fundamentalist view of health as a commodity. Instead of Alma-Ata’s demands for an NIEO free from ‘unacceptable’ inequalities between rich and poor, and instead of seeking to advance PHC globally with international cooperation, the idea was that economic growth would eventually lead to good health. This was itself an idealistic and highly normative vision of a new economic order, but it was a neo-liberal order founded on an idealisation of market rule. By unleashing global market competition in the name of securing stabilisation amidst globalisation, it bound the indebted countries under World Bank and IMF rule into a straitjacket of forced neo-liberalisation. Coinciding with the global AIDS epidemic, the impacts of structural adjustment on health and health systems were devastating. The commodification and privatisation of health services reduced the availability of both treatment and prevention options for poor patients. The adoption of user fees failed to cover the costs of broader public health measures such as education, sanitation, and even the collection of basic life and death statistics. Health worker brain-drain dynamics that were set in motion in the context of public sector pay cuts, and the increasing precariousness of employment in defunded public health systems further deprived poor patients of reliable health services, including the kind of primary health services close to home and work envisioned at Alma-Ata.

Globalisation and the Politics of Global Health   47 Meanwhile, trade deals and the deregulation of foreign direct investment frequently led to the destabilisation of rural farm economies, destroying jobs and undermining food security simultaneously. Combined with the austerity imposed on health systems, access to life-saving medicines was further compromised by the monopoly pricing that was expanded across borders by the drug patent protections built into new free trade agreements. Despite this damage, economists associated with the World Bank continued to idealise a utopian vision of neo-liberal globalisation, in which increasing wealth was supposed to lead to health, well into the 1990s (Pritchett and Summers 1996). But by the end of the decade most observers involved in delivering health services to poor communities saw a deadly dystopia instead. Highlighting the colonial continuities in places such as Haiti, Farmer argued that structural adjustment was inflicting neocolonial kinds of ‘structural violence’ on the bodies of the poor (Farmer 2004). In a comprehensive critique, Farmer’s colleague Jim Kim joined with other critics to blame the neo-liberal assumptions of the Washington Consensus: ‘The idea that robust economic growth will automatically lead to a better life for everybody is comforting. . . . Unfortunately, it is also wrong. Specific growth-oriented policies have not only failed to improve living standards and health outcomes amongst the poor, but also have inflicted additional suffering on disenfranchised and vulnerable populations’ (Kim et al. 2000). One other indicator and outcome of globalisation was that the neo-liberal assault on protective state services impacted rich countries too. Enabled by different mechanisms in different contexts, its globalising reach was matched by an individualising emphasis on the personal responsibilisation of health as a matter of self-investment. Rich countries like the United States and United Kingdom saw the push towards privatisation and deregulation driven forward by conservative politicians such as Ronald Reagan and Margaret Thatcher, to be only slightly softened by advocates of personal responsibilisation such as Bill Clinton and Tony Blair (Schram 2000). In Asia, experiments in state-led global integration also proceeded apace, often also involving various innovations in personal self-investment despite the lack of democratic freedoms (Zhang and Navarro 2014). And in the former Soviet bloc, a much more radical transition from state management to overnight marketisation after 1989 led to the sudden transformation of free public healthcare and medicines into privatised commodities for which individuals had to pay out of their own pockets. Indexing the further demise of the vision of Alma-Ata globally, the resulting user fees led locally to declining health and increasing deaths across the former USSR, including in regions nearby where ‘Health for All’ had originally been declared (Keshavjee 2014). Beyond the impacts on healthcare itself, the binding of neo-liberalisation with ­globalisation in the 1990s has since had wider negative ramifications for the social determinants of health globally. In-country inequalities in income have increased, with more wealth being captured by the global investor class, along with increasing health vulnerabilities for the poor and economically precarious (Oxfam 2018). Trade deals have further entrenched intellectual property protections, expanding the monopoly pricing of medicines globally through the World Trade Organization’s Trade-Related Aspects of

48   Matthew Sparke Intellectual Property Rights (TRIPS) rules (Kapczynski 2009), and increasing ­restrictions on generics with new ‘TRIPS plus’ rules on data exclusivity (UN 2016). Trade-based competition from countries with lower taxes and lower protections for workers and the environment intensified a ‘global race to the bottom’ in political, legal, and environmental standards, thereby creating a convergence between industrial and eco-social threats to health whilst limiting the ability of governments to protect (Labonté et al. 2009, Labonté and Stuckler 2016; Peckham et al. 2017). And in the heavily indebted poor countries (HIPC) of the global South, poverty reduction strategy papers (PRSPs) have picked up where the much-critiqued SAPs left off, albeit allowing debt-disciplined governments to draft their own neo-liberal reform strategies in the name of ‘country ownership’ (Pfeiffer and Chapman, 2010). Reviewing these developments in 2008, the WHO Commission on the Social Determinants of Health concluded: ‘Inequalities are killing people on a grand scale’ (WHO 2008, 6). The commissioners did not describe the associated mechanisms explicitly as neo-liberalism, but they did highlight how the ‘structural drivers’ of ‘bad policies, economics, and politics’ had gone global with globalisation. ‘These “structural drivers”’, they concluded, ‘operate within countries under the authority of governments, but also, increasingly over the last century and a half, between countries under the effects of g­ lobal­i­sa­tion. This toxic combination of bad policies, economics, and politics is, in large measure, responsible for the fact that a majority of people in the world do not enjoy the good health that is biologically possible’ (WHO 2008, 26). Appearing in early 2008, the report was both perfectly timed and terribly timed. An epic crisis of market-led globalisation rocked the world just as it was being published. Vindicating the commissioners’ arguments about toxic economics and politics, but also replacing their concern with all those left behind by global health improvements, the crisis created a new frenzy of global concern with the ‘too big to fail’ economic actors at the centre of the global meltdown. Yet again an ideational legacy of AlmaAta—in this case, the 2008 report’s systematic emphasis on the social determinants of ill-health globally—was eclipsed by a material breakdown in the markets of economic globalisation. The following year, in an extraordinary speech before the World Health Assembly, WHO director-general Margaret Chan did her best to bring back a critical social-determinants approach to interpreting the multiple crises of neo-liberal globalisation. She too did not refer to neo-liberalisation explicitly, but her epidemiological overview presented a  compelling critique of globalisation. ‘The rising tide of globalisation has not lifted all boats’, she complained. ‘Instead, wealth has come in waves that lift the big boats but swamp or sink many smaller ones’ (Chan 2009). Chan’s criticism of market-led ­globalisation perfectly summarised a widespread sense of disillusionment with the old Washington Consensus. Good economic growth was not leading to good health. The processes producing growth were instead creating uncontrollable crises in the basic life support systems of the planet. But in the aftermath of similar announcements of disillusionment by other world leaders, we have not seen a return of Alma-Ata commitments to government-supported universal health rights. Instead, as we review in the

Globalisation and the Politics of Global Health   49 next section, a new Washington Consensus has emerged. This acknowledges the many macro-market failures of globalisation but idealises micro-market partnerships in order to expand selective, disease-specific vertical interventions as the global health solution.

Global Health Selectivity and the New Washington Consensus Disease-specific, vertical approaches to international health are not new. They have a long history going back to colonial health regimes. As Packard explains, their influence, and their associated bias towards biomedical solutions imposed from afar, continued throughout the twentieth century (Packard 2016). Whenever more horizontal approaches and ideas about addressing the social determinants of health attracted support, countermovements quickly followed, shifting policy back away from universality towards ­disease-specific selectivity. Most notably after Alma-Ata, the response came in the form of selective primary healthcare (SPHC), a countermovement that for PHC promoters at WHO appeared as a ‘counter-revolution’ (Newell 1988; see also Cueto in this volume). Supported by the Rockefeller Foundation, the United Nation’s Children’s Fund (UNICEF), the US Agency for International Development (USAID), and the World Bank, SPHC was argued to be a cost-effective way of targeting interventions to a limited number of diseases in order to maximise the number of lives saved with limited resources. The selectivity of UNICEF’s ‘Child Survival’ programming, led by Jim Grant’s calls for ‘emergency’ action with GOBI (growth monitoring, oral rehydration, breastfeeding, and immunisation), thereby came to dominate the PHC plans Mahler had been championing as director of WHO (Cueto 2004). This is important to note because the same cost-effectiveness concern with rationing scarce global resources has endured into the twenty-first century, creating the basis for today’s financialised focus in global health on maximising returns on investment. However, along the way the Washington Consensus that contributed to the health emergencies amidst which SPHC was first justified has morphed into something new (Mitchell and Sparke 2016). In short, the new Washington Consensus is that investments in health are needed to generate wealth for communities stuck in cycles of poverty and illness. Competitive market-led globalisation is still understood as the unavoidable backdrop of policymaking, but it is not assumed to lead naturally from economic growth to health. Instead of ‘Wealthier is Healthier’, the putative causal connection is inverted to argue that cost effective, targeted interventions must be invested to open opportunities for global capitalist reintegration and growth. Led by Bill Gates and other executives who have brought their business methods to the cause of expanding global health, the repeated refrain is that with ‘professional’ and ‘measurable,’ results-based financing the targeting of investments will continue to improve, and the resulting returns on investment will themselves help legitimate yet more investments (e.g., BMGF 2017). ‘The bottom line’, Gates wrote

50   Matthew Sparke in bold in his 2014 foundation letter, is that ‘[h]ealth aid is a phenomenal investment’ (Gates 2014, 15). And in the same bolded format, the Lancet Commission’s Global Health 2035 report more recently reached the same consensus conclusion: ‘There is an enormous payoff from investing in health’ (Jamison et al. 2013, 1898). Even though its twenty-first-century advocates do not use the term, the New Washington Consensus works as a name for this investment-oriented approach to global health governance for at least four institutional reasons—in addition to the fact that the Gates Foundation is based in Seattle, Washington, rather than in Washington, DC. First of all, the New Washington Consensus has clearly grown out of policy adjustments made by the World Bank itself amidst the calls for structural adjustment with a human face. Second, the new ‘common sense’ has involved policymaking shifts at WHO and the development of new global health agencies—most notably the Global Fund to Fights AIDS, Tuberculosis and Malaria (the Global Fund) and the Global Alliance for Vaccines and Immunisations (GAVI)—that have amplified the arguments about health investments leading to global economic growth. Third, the New Washington Consensus really is new in its twenty-first-century commitment to creating global networks of public-private partnerships, many of them organised in ways that sideline national governments whilst making micro-market innovations designed to tackle the health problems created by macro-market failure. And fourth, the New Washington Consensus, just like the old consensus before it, is clearly not a global consensus, but rather a dominant policymaking regime with diverse critics who contest the beneficent vision of targeted health investments leading to healthy, productive lives for all. As we shall now review, all of these developments are connected in turn to evolving debates and discontents about the neo-liberalisation of globalisation. Both at the World Bank and amongst other economists in DC, the original Washington Consensus was supposed to encourage investments in PHC and education. This was in fact the second reform on Williamson’s original list of ten consensus norms (Williamson 1990). The problem was that all the upheaval and austerity forced on indebted countries by SAPs made such investments by national governments impossible. Nevertheless, back in 1993 the seeds of the World Bank’s new solution were sown in the form of the influential Investing in Health report (World Bank 1993). The report contained much of the normal consensus cant about achieving health through the pursuit of pro-market, macroeconomic growth policies, but it also included a new SPHC-inspired attention to making targeted, cost-effective investments in ‘minimum packages’ of interventions such as immunisations. To rank and justify the priority of such packages in terms of return on investment, the report in turn presented metrics of the global burden of disease (GBD) as measured in terms of disability adjusted life years (DALYs), the latter being calculated as the sum of years lost to premature death and to life lived with disease and disability due to a comprehensive list of causes. The goal of creating this single ­globally comparable metric was to enable cost-effectiveness comparisons of the number of DALYs averted by different targeted interventions per dollar spent, thereby enabling the comparison of returns on investment by type of intervention, cause of illness, and country across the whole world. Critics highlight

Globalisation and the Politics of Global Health   51 how the method’s weightings for age and disability impose neo-liberal assumptions about human capital being the ultimate meas­ure of human value (Kenny 2017; Laurie 2015). Kenny further underlines how this economisation of life also represents in turn a fundamental shift from ‘Health for All’ to ‘Health as an Investment’ (Kenny 2017). But it is nevertheless these globalised DALYs-per-dollars cost-effectiveness comparisons that have subsequently gone on to become such an influential method of global health governance. The 1993 Investing in Health report’s arguments in favour of targeting selective investments on measurable results had an enduring impact at the World Bank itself, where it led to a new insistence on investments in health leading to wealth (e.g., World Bank 2007). But this reversal of the old Washington Consensus also started to spread in the new millennium within other institutions of global governance as well, not least of all at WHO. As Nitsan Chorev explains, the process involved both institutional accommodation and adaptation of neo-liberal norms, with WHO director Gro Harlem Brundtland playing a leading role in arguing that the adoption of investment ideals would help secure support for the organisation’s global health goals from world leaders and their finance ministers (Chorev 2013). Addressing WHO’s Executive Board in 1999, she stated: ‘We . . . know that sound investments in health can be one of the most cost-effective ways of promoting development and progress. Improving health in poor countries leads to increased GDP per capita’ (quoted in Chorev 2013). She then proceeded to organise the WHO Commission on Macroeconomics and Health. Brundtland charged her commission with a straightforward claim: ‘That poverty causes ill health is well known. But good health can fuel the engine of development. . . . This is the case we have to make’ (quoted in Chorev 2013). And make it they did, thereby also showing how the investment and measurement mindset could itself travel globally. Beyond Washington State, Washington, DC, and WHO, the new Washington Consensus on targeted, cost-effective investments has spread as a ‘common-sense’ approach to global health governance far and wide. Nowhere are these patterns more clear than at the organisations that are increasingly taking over from WHO as the Geneva-based nodes of global health governance: namely, the Global Fund, GAVI, and Roll Back Malaria. They all stress results-based financing, with targeted disease-specific ‘investments for impact’. They all involve extensive public-private partnerships as coordinating mech­ anisms. And whilst they are careful to talk about health systems strengthening and sustainability, they take the meaning of systems in a highly technical and logistical direction, elevating partnerships with market actors as the main mechanism for strengthening and sustaining their vertical interventions in country-specific market systems (Storeng 2014). This is a far cry from the national governmental responsibility for PHC declared at Alma-Ata. Instead it is a consensus approach that systematically reduces the role of  governments to that of being co-funders or collaborators in market-mediated coordination mechanisms. For the same reason, it is, not surprisingly, one of the important reasons that there is considerable global dissent against the new norms of global health governance associated with selective targeted investments in disease-specific vertical interventions.

52   Matthew Sparke Just as the old Washington Consensus dissembled dissent around the world, today’s economistic expertise about global health investment obscures a great deal of dissensus, all of it animated by an overarching concern with how the new common sense remains bound and led by neo-liberal ideas about globalisation. Along with the lack of democratic accountability and the challenges created for national government planning, common concerns raised by critics include the lack of attention to how globalising capitalism itself creates health vulnerabilities; the fascination with magic-bullet biomedical solutions; the problems of internal brain drain, created by pulling health workers out of  frail and underfunded national systems to work in better compensated jobs in ­disease-specific programmes; the skewing of development towards market-mediated partnerships; the associated proliferation of multiple uncoordinated non-governmental organisations (NGOs) pitched into competition with one another; the undermining of sector-wide approaches (SWAps); and the resulting patchiness of inclusion and enfranchisement with meaningful health rights (Birn 2005; Legge 2016; McCoy et al. 2009; Pfeiffer et al. 2017). The complex triaging of who gets to count as a ‘therapeutic citizen’ amidst this patchy politics of disease-specific global health programming has led some front-line physician-ethnographers to describe the politics of global health in terms of ‘republics of therapy’ and their excluded others (Kalofonos 2010; Nguyen 2010). And whilst this ‘works’ in the sense of creating new global health subjects, it has also lead to what Reid-Henry calls ‘the failure of global health as a field of governance’ (Reid-Henry 2016, 713). In the end, argues Reid Henry, this systemic failure means that ‘[m]ainstream global health today seeks to fill the potholes of global ill health; it does not reconstruct the road itself ’ (2016, 721). Let us conclude this overview therefore by reflecting on how vulnerable this unreconstructed global market road now makes global health in the context of reactionary attacks on globalisation from the right.

Conclusion: Global Health Politics amidst Antiglobalisation Reaction If, as Youde has argued, ‘global health governance itself has woven its way into the normative fabric of international relations’ (2017, 583), the central argument of this chapter is that the thread of neo-liberalism has been woven into this fabric through a series of norm-setting ties that bind. From the eclipse of Alma-Ata by structural adjustment and Washington Consensus reforms in the 1980s and 1990s, to the rollout of New Washington Consensus norms of targeted cost-effective interventions in the new millennium, we have seen how this thread has twisted and turned. Creating structural violence, vulnerability, and ill-health in one turn, it has also gone on to be twisted into the conceptualisation and advocacy of idealised solutions in the next turn. Through all these twists and turns, neo-liberalism has clearly bound and led global health gov­ern­ ance globally, nationally, and personally. And because it is also now so clearly bound up

Globalisation and the Politics of Global Health   53 with the ways in which people in general and policymakers around the world view ­globalisation, the neo-liberalisation of global health looks set to evolve again as globalisation itself is challenged by a new set of antiglobalist leaders. Today’s norms of global health governance now seem highly vulnerable to all the political upheaval associated with Far Right reactions against neo-liberal globalisation. This is a politics of reaction which, in the aftermath of Trump’s triumph in the US 2016 presidential election, looks set to undermine all kinds of Washington Consensus, both Old and New. Articulated in diatribes against globalisation and the maligning of ‘globalists’, the resulting ‘emergency’ in the idea of the global now profoundly threatens the ideas underpinning global heath governance in all its forms, including the targeting of programmes at especially vulnerable populations such as poor women. Indeed, in an early sign of this reactionary remaking of global health policy, Trump began his presidency by reinstating the so-called Mexico City Policy, also known as the ‘global gag rule’ on women’s reproductive health, banning US aid to any international organisation that supports abortion-related activities (Lo and Barry 2017). Public funding for global health in this new reactionary context looks increasingly precarious, as too does international political agreement on global public health security regulations, pandemic preparedness, and planetary health proposals predicated on a recognition of climate change science. President Trump’s May 2017 budget sent to the US Congress began by proposing sweeping cuts in global health funding. These included: a 17 percent cut to the Global Fund; 17 percent cuts to bilateral President’s Emergency Plan for AIDS Relief (PEPFAR) programmes; a 10 percent cut to State Department HIV/AIDS funding; a 50 percent cut in the Centres for Disease Control’s AIDS budget; the complete elimination of the HIV/AIDS programmes at USAID; and the elimination of funding for research into an HIV vaccine (HealthGap 2017). Later in September, the Senate rejected President Trump’s proposed cuts. But this was just the start of an ongoing struggle, one in which the fact-free and fear-mongering rhetoric of the president has already gone on to assert that all Haitians have AIDS and that they and citizens of other ‘shit-hole countries’ should be excluded as immigrants to America. In response, many emergent political scenarios seem possible, including some that might even merge the pro-equity, pro-planet, pro-facts traditions that remain integral to global health (Garay and Chiriboga 2017; McKee and Stuckler 2017; Ooms et al. 2017). At the World Economic Forum in Davos in 2018, executives from the Gates Foundation promoted their new campaign to tackle malaria globally, arguing that donors should incentivise countries to invest more themselves because of the great return on investment involved: ‘Leading economists have identified the fight against malaria as one of the ‘best buys’ in global development’, they noted, ‘calculating that a 50 percent reduction in global malaria incidence could produce $36 in economic benefits for every $1 invested’ (Mundel and Suzman 2018). Whether or not these economistic arguments will persuade the Trump administration and other reactionary regimes remains to be seen. It seems a very thin thread on which to hang such huge global hopes. But in a world shaped by globalisation, it remains as this chapter has argued throughout, a remarkably persistent neo-liberal thread.

54   Matthew Sparke

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chapter 4

The Politics of Gl oba l H e a lth I n equa lities Approaches to Studying the Role of Power Yusra Ribhi Shawar and Jennifer Prah Ruger

Health inequalities are a widely recognised and pervasive problem, existing over time in most countries where they have been studied (Mackenbach et al. 2008). They arise as a result of an array of social factors, including race, ethnicity, education, gender, geography, and social class (McCartney, Collins, and Mackenzie 2013) as well as economic and political determinants. Health inequalities are especially stark when considering mortality rates amongst countries. Compared to the global average, children are fifteen times more likely to die before the age of five in sub-Saharan Africa (WHO 2018). A woman in Sweden has less than a 1 in 10,000 lifetime risk of maternal death compared to a woman in Chad, who has a risk of 1 in 16 (WHO 2017). Approximately 80 percent of the 35 million deaths from non-communicable diseases (NCDs) annually occur in low- and middle-income countries (LMICs) (WHO 2005). Health inequalities are also observed within countries: in most western European countries, the excess mortality rate (death occurring prior to the average life expectancy for a person of a particular demographic category) in lower socio-economic groups is 25–50 percent higher than in higher socio-economic groups (Mackenbach 2006). For instance, there is a twenty-year difference in a man’s life expectancy between two neighbouring inner-city communities in the US city of Baltimore, and a similar avoidable disparity between the poorest and wealthiest individuals across the United States (Marmot 2015; Chetty et al. 2016). Whilst scholarly interest in health inequalities has existed since the nineteenth ­century (Waitzkin  1981), global interest in the subject has increased over the past ­several decades, and especially since 2005, with the formation of the World Health Organization’s Commission on Social Determinants of Health (Cash-Gibson et al. 2018;

60   Y. R. Shawar and J. P. Ruger WHO 2019). Historically, much of the associated research highlights the importance of fostering economic growth, improving broader social policies, and scaling-up technical and biomedical solutions to reduce health inequalities. More recently there has been greater recognition that achieving these goals requires a closer examination of politics at the global, national, and subnational levels and across the multiple sectors impacting health (Otterson et al. 2014; Kickbusch 2015). Whilst there is a growing body of scholarship that recognises the importance of examining how different power constellations shape health inequalities, careful analyses of politics and particularly power within the health inequalities literature remains limited. The goal of this chapter is to examine how power has been understood and analysed to date with respect to health inequalities and to identify ways forward for using expanded concepts of power to deepen understanding of why health inequalities persist. After reviewing the state of health inequality scholarship and the emerging interest in considering the political determinants of health, including the nature and role of power, the chapter presents the various conceptualisations of power that are used and how it is measured in this literature. The chapter ends with a discussion of strengths and limitations of this literature, as well as potential ways forward for embedding the study of power more deeply in analyses of health inequalities.

The Study of Health Inequalities Research on health inequalities and inequities is substantial and growing. Health inequality refers to the ‘differences, variations, and disparities in the health achievements of individuals and groups’, whilst health inequity pertains to ‘those inequalities in health that are deemed to be unfair, stemming from some form of injustice’ and/or are unavoidable or unnecessary (Dahlgren and Whitehead 1991; Kawachi, Subramanian, and Almeida-Filho 2002, 647). The former is a dimensional concept, referring to meas­ ur­a­ble quantities, whilst the latter suggests a moral commitment to social justice. Whilst recognising the overlap of the two terms and the explicit link that health inequity has to politics and power, given that understanding a health indicator difference that is rooted in a form of injustice necessitates an investigation of power, we use health inequality in this chapter, given its inclusivity of a broader body of scholarship. Measurement of health inequalities often involves comparing an indicator of health or a health-related factor in one or more disadvantaged groups—for example, women, the poor, racial or religious minorities, or other populations that consistently experience societal disadvantage—with the same indicator in a more advantaged group or groups (Braveman  2006) or analysing shortfall inequality (Ruger  2006; Ruger and Kim 2006). Over several decades, this body of research has made important contributions by pinpointing many underlying drivers of health inequalities (e.g., CSDH 2008; Marmot 2010), identifying linkages between health inequalities and individual behaviours and risk factors (e.g., Kawachi, Daniels, and Robinson 2005), and evaluating the

Politics of Global Health Inequalities   61 impact of various policies and programmes on health inequality outcomes (e.g., McGill et al. 2015). However, scholarship in this area has struggled to systematically study the upstream social, political, and economic contexts within which health inequalities are produced and perpetuated, as well as the specific role of power in these dynamics. A major gap in this literature is analyses of power that uncover relational and structural mechanisms that underpin health inequalities (Ng and Muntaner 2014). The relative dearth of explorations of power has disciplinary origins. There remains a strong biomedical bias in health and healthcare-related areas of research, which leads to a tendency to concentrate on ‘the immediate biological, and sometimes behavioural, causes of illness and death’ (CSDH 2008) instead of drivers deep seated in politics and power (Forman 2019). Accordingly, the identified determinants of health inequality tend to be conceptualised and measured as ‘single reducible categories’, regularly reproduced in these epidemiological and biomedical approaches, instead of considering them as ‘complex social locations that shape the experience of health in important ways’ (Hankivsky and Christoffersen 2008).

The Conceptualisation of Power in Global Health Scholarship Power is a key concept of study in the social sciences. Dahl (1957, 202–203) defined power, in his seminal study, as ‘the ability of A to get B to do what B otherwise would not do’. However, other scholars draw attention to power’s dynamic and multiple forms, going beyond Dahl’s conceptualisation, which captures only one overt form of power. These diverse conceptualisations and resultant approaches to studying power are a source of scholarly debate. There are ongoing deliberations about the nature and role of power; who holds it and who does not; how actors exert it (i.e., power over, which relates to an actor’s influence over others, versus power to, which concerns an actor’s ability to accomplish proposed goals or act in concert); its sources (i.e., mandate, charismatic, financial, expertise, physical force, etc.); and how to reconcile power that stems from human agency—control that is exerted directly or indirectly by one actor over another— with structural power—that which is embedded in and produced by economic, social, political, and ideological structures. Accordingly, the study of power is challenging, both conceptually and empirically. Overall, power is conceptualised from multiple disciplines; has a ‘polymorphous character’ (Barnett and Duvall  2005, 40), defined to encompass a variety of phenomena; and may even be ‘in principle unobservable and can only be studied indirectly’ (Murphy 2011, 94). Despite these challenges, there is widespread awareness of the importance of understanding power in global health. Indeed, no fewer than eleven commentaries (e.g., Lee 2015; Ooms 2015; Bump 2015; Forman 2016) discussing power in global health were

62   Y. R. Shawar and J. P. Ruger published between 2014 and 2016 in response to the observation that ‘power is exercised everywhere in global health’ (Shiffman 2014, 297). There is also increasing awareness of its manifestation in multiple forms in global health. Beyond the possession and exercise of power through material or financial sources, power is also exerted via technical expertise, ideas, institutions, and global networks (Shearer et al. 2016; McDougall 2016; Shawar and Crane  2017). Accordingly, global health scholars have called for more empirical investigations of diverse forms of power to enhance understanding and ultimately to ‘tackle the political determinants of global health’ (Kickbusch 2005). Since the mid-2000s, power has been studied to better understand health systems in LMICs (George et al. 2015; Sriram et al. 2018), health priority-setting (McCollum et al. 2018), health policymaking and implementation (Buse et al. 2009; Erasmus and Gilson 2008; Buse and Hawkes 2014; Shiffman 2014; Dalglish et al. 2015; Mwisongo et al. 2016; Marten 2019; Gore and Parker 2019), and its particular influence on front-line health service delivery in LMICs (Sheikh and Porter 2011; Lehmann and Gilson 2013; Velloso, Ceci, and Alves  2013; Erasmus  2014; Erasmus et al.  2014; Storeng and Mishra  2014; Gore 2019). There is also a nascent body of literature that explicitly examines the role of power with respect to health inequalities, which is the focus of this chapter.

The Study of Power in Relation to Health Inequalities Scholars studying the role of power in shaping health inequalities have drawn on scholarship and approaches from the disciplines of anthropology, political science, and sociology, amongst others. How power has been studied to date can be presented in a number of ways, including the source of power, the ways in which it manifests or is exerted, and the level at which power exists (individual, community, national, or global). The review in this chapter is organised by discipline to highlight the unique terms and approaches of study that each body of scholarship contributes to studying power in relation to health inequalities. Key studies are identified that examine power by discipline, highlighting the major conceptualisations, theories, and/or frameworks used, as well as the methods of analysis applied.

Anthropology Scholars have drawn widely on concepts and methodologies from anthropology and critical medical anthropology to study the role of power in health inequalities. In particular, anthropology has advanced the concepts of ‘structural violence’ and ‘structural vulnerability’ as central concerns to understanding how power is embedded in, and produced by, societal structures and discourses.

Politics of Global Health Inequalities   63 The term structural violence is defined as ‘the indirect violence built into repressive social orders creating enormous differences between potential and actual human self-realisation’ (Galtung 1975,173). Structural violence is used in the health literature to describe the effects of political-economic systems of oppression on the health of the poor (Farmer 1997, 2003, 2004). These investigations ground health inequalities in relation to ‘upstream constellations of international political economy, regional history, and development ideology’ (Janes and Corbett 2009). Through such analysis, the external and embedded forces of power (i.e., stemming from globalisation) by which particular populations experience suffering or sickness within their local communities (i.e., class-based economic exploitation) are exposed (Quesada, Hart, and Bourgois 2011). The term structural vulnerability extends the economic, material, and political insights of structural violence to encompass more explicitly the cultural causes of physical and mental distress, including, for example, gender inequality and racism. Accordingly, structural vulnerability considers the interface of an individual’s personal attributes (i.e., appearance, ability, sex), with institutional structures and cultural values (Quesada, Hart, and Bourgois 2011). In medical anthropology, structural violence and/or vulnerability has been used to highlight health inequalities by identifying socially structured patterns of distress and disease across population groups (Maternowska 2006). Scholars tend to employ ethnography to simultaneously track power dynamics at the individual level, as well as within the social, physical, and economic contexts. For example, Goldade (2009) explores the barriers to medical care for undocumented Nicaraguan migrant women in Costa Rica through a close examination of the day-to-day and migrant-provider experience of a particular woman—Isabel—whilst also exploring how her experiences interact with the broader historical processes of Costa Rican health and economic reforms. In particular, these studies typically employ the classic anthropological technique of participant observation, which involves the investigator’s long-term immersion in a particular social and cultural context. Over the course of the research project, the investigator participates in everyday life, ‘observing interactions and listening to conversations in order to identify significant practises, political economic forces, and ­cultural concepts’ (Holmes 2006). For example, Holmes (2006, 2007, 2011) actively participated in the Tanaka berry farm for over a year (e.g., engaging in berry-picking activities) in order to explore the structural vulnerabilities experienced by various actors on the farm, including US citizen Anglo-Americans, US citizen Latinos, undocumented mestizo Mexicans, and undocumented indigenous Mexicans. Based on three years of participant observation in Mozambique, Pfeiffer (2003) exposes the exercise of power by international non-governmental organisations (NGOs) and donors over the local population, including local health workers. By fragmenting the health system, the author observes international actors undercutting local control of health programmes and contributing to growing local social inequality in Mozambique. Accordingly, ethnography uniquely allows for the investigation of multiple forms of data and multiple points of view. Whilst ethnography may also include data from interviews and surveys, ‘it differs significantly from many other methods of research in that it

64   Y. R. Shawar and J. P. Ruger is performed and analysed within the situational knowledge provided by long-term participation, observation, and relationship’ (Holmes 2006). This is particularly important when studying power dynamics because ethnography, compared to research methodologies and approaches that do not embed an investigator for an extended period in the everyday lives of communities that are the subject of research, generates data and analyses that more fully represent the complex realities that individuals navigate, which ultimately shape their health access and experience. In addition, the long-term involvement of investigators in the lives of vulnerable populations helps to build rapport that can enhance the validity of data, especially when sensitive matters that relate to power are being studied (Holmes 2006). Examining health inequalities through a structural violence or vulnerability lens leads investigators to examine the embedded social and political forces that constrain or determine health decision-making and behaviour and ultimately limit life outcomes. This approach is particularly helpful for better understanding how structures confine agency in ways that put individuals in circumstances of increased vulnerability. For example, Desai (2016) finds that the reason low-income, rural women in India increasingly decide to undergo a hysterectomy—unnecessarily normalising it as a permanent solution for gynaecological ailments—concerns structures of power, notably their low place in the social hierarchy. The type of power studied by investigators using this lens is less that expressed by one actor over another and more how it is embedded in societal structures. These conceptualisations are useful for contextualising diagnosis and health behaviours (Singer and Baer 1995). Importantly, they also remove the assumption that individuals necessarily have agency or control over their health outcomes, redirecting ‘blame and interventional attention from the victims of suffering and towards the societal structures producing and organising their suffering’ (Holmes 2011, 426).

Political Science Researchers studying health inequalities have also drawn on concepts and methodologies from political science, and in particular political economy, to understand the role of power. Through a political economy lens, researchers studying health inequalities consider how social classes, occupations, and parties, for example, act through political and economic systems at the state level to influence the allocation of resources, which in turn impacts health outcomes (Coburn 2010). In particular, this approach investigates the effects of income equality via the spread of neo-liberalism; the decline of the welfare state; differences amongst states regarding type of welfare regime; and the broad dynamics amongst class structure, economies, and human well-being (Coburn 2004). Adopting a political economy lens, scholars have also examined how the power exerted through political ideology (i.e., neo-liberalism), trade liberalisation, and/or the business practises of transnational corporations shape the public policies that create and sustain health inequalities (Navarro  2002,  2007; Navarro and Muntaner  2004; Chernomas and Hudson  2007; Raphael  2014). For example, economists Chernomas

Politics of Global Health Inequalities   65 and Hudson (2007) examine how the dominance of business power and the ideology that supports it have increased illness and mortality in certain populations. They demonstrate how the substantial capacity of the business sector to influence public policy decisions via lobbying, advocacy, and funding of business-friendly research and policy debate can result in harmful effects on public interests and the environment. Coburn (2000, 2001, 2004) describes how capital, in the form of economic globalisation and underpinned by neo-liberal ideology, acts through certain forms of the welfare state to shape the social determinants of health. Coburn (2004) traces health inequalities back to political trends at the national and global levels that have reduced the power of lower socio-economic classes and increased the power of the business class. Furthermore, he ascribes cross-country health inequality magnitude differences to differential country resistance to international pressures towards neo-liberal policies, which he finds is shaped by a state’s historical and institutional structures. There is also a sizeable literature that draws on welfare state regime theory or the ‘worlds of welfare’ framework (Esping-Andersen 1990, 1999), which advances the welfare state as a key explanatory factor for health inequality (Eikemo et al. 2008; Bambra, Netuveli, and Eikemo  2010; Raphael  2011,  2014; Muntaner et al.  2011; Raphael and Bryant 2015). This literature examines the origins and characteristics of social democratic, conservative, and liberal welfare states and the power dynamics embedded within political and economic structures and processes that can impact health and create health inequalities. For example, Raphael and Bryant (2015) considers the power differentials across a capitalist economy’s business, labour, and civil society sectors, highlighting how a differential balance of power across these sectors has distinctive impacts on the social determinants of health within social democratic welfare states (Nordic countries), liberal welfare states (Anglo-Saxon countries), and conservative welfare states (European continental countries). Analysis from a shared health governance perspective illuminates a rational actor model of global health governance in which actors and institutions in the global health system fail to adhere to principles of global health justice, which seek to equalise power amongst global citizens through equal respect for all individuals’ health (Ruger 2012).

Sociology Drawing on the discipline of sociology, health inequality researchers have sought to understand both structural and agency forms of power through the examination of institutions and stigmatisation, often advanced within Marxist and neo-Marxist perspectives. Although explicit investigations of institutions and health inequalities are limited (Gkiouleka et al. 2018), researchers recognise the major role social institutions play in the politics of health and the underlying causes of health inequalities (Beckfield et al. 2015). There is also an increasing awareness that institutions do not merely facilitate the distribution of health gains or losses, but they also embody and articulate power relations—often enabling particular populations to sustain health privileges at the cost

66   Y. R. Shawar and J. P. Ruger of others (Weber and Parra-Medina  2003). Accordingly, through an examination of power relations encompassed in institutions, Sainsbury (2006) examines the disproportionately negative impact of welfare reforms in the 1990s on immigrants’ and noncitizens’ social rights. Greer Murphy (2017) investigates the impacts of recent austerity policies on women’s health. Scott et al. (2017) draw upon the concept of social spaces in their investigation of how power inequalities are produced through village health, sanitation, and nutrition committees (VHSNCs) in rural India, which were established to encourage community participation in health promotion activities and strengthen community relations with related government services. ‘Social spaces’ (Lefebvre 1991) refer to ‘moments in space and time, constructed through relationships between diverse groups, which create contexts for new social representations and identities to emerge’ (Duveen and Moscovici 2000). The authors trace the ways in which the VHSNCs influence power relations (i.e., around gender) within communities and how the rationale for participation framed by outside stakeholders influences community collective agency (Scott et al. 2017). Power in the sociological health inequalities literature has also been studied through an examination of stigma. Historically, studies of stigma were mostly drawn from social psychology, highlighting the impact of attitudes associated with stigma on discriminatory practises and ultimately health outcomes. More recently there has been growing acknowledgement of the central role of power, with stigma defined as the ‘relations of power and exclusion that reinforce vulnerability within a complex social and political process’ (Parker 2012). From a sociological perspective, stigma is thus defined as ‘the co-occurrence of labelling, stereotyping, separation, status loss, and discrimination in a context in which power is exercised’ (Link and Phelan 2001). Sociologists offer useful studies of how stigma manifests in healthcare encounters, community discourses, and even national policies, producing health disparities in specific populations, such as those with HIV and AIDS (Davtyan et al. 2017); transgender populations (Poteat, German, and Kerrigan 2013); and those living in particular geographies, known as ‘place-based stigma’ (Bush, Moffatt, and Dunn 2011; Cattell 2001; Popay et al. 2003; Pearce 2012; Keene and Padilla 2014; Thomas 2016). For example, in their examination of how stigmatisation functions in healthcare encounters between transgender patients and medical providers, Poteat, German, and Kerrigan (2013, 22) find that the uncertainty and ambivalence of providers when interacting with transgender patients in the medical encounter ‘upsets the normal balance of power in provider-patient relationships’. Accordingly, interpersonal stigma functions to reinforce the power and authority of the medical provider during these interactions. Researchers studying health inequalities have also examined the ways in which the wealthy and powerful shape policies in ways that contribute to health inequalities—a strand of research that remains under-explored (Garthwaite et al. 2016). This body of literature builds on particular threads of Marxist or neo-Marxist theory (Muntaner et  al. 2015; Scambler and Scambler  2015; Raphael and Bryant  2015) and employs ­historical materialism, a methodology that focuses on human societies and their development throughout history; it argues that history is the result of material conditions rather than ideas. It often is used in analyses and critiques of the development

Politics of Global Health Inequalities   67 of  capitalism. In particular, sociologist Graham Scambler (2002,  2007,  2009,  2012) brought attention to this area of research in the health literature via his advancement of the ‘greedy bastards hypothesis’ (GBH). A neo-Marxist theory of health inequalities (Scambler  2009), GBH asserts that Britain’s persisting health inequalities are largely a result of the inadvertent consequences of capitalist power elites. Applying this theory, he traces the way in which powerful elites exert power, leading to health inequalities, through an analysis of the pension crisis and the global financial crisis (Scambler 2012).

Critical Theory In addition to the three disciplines just discussed, it is useful to recognise the role of critical theory as a cross-cutting perspective oriented towards critiquing and transforming all aspects of society, as opposed to describing or explaining it. Critical theory offers an expanded understanding of power inequalities through two lenses: critical race theory (CRT) and intersectionality.

Critical Race Theory CRT is a body of critical theory that focuses on how racism is embedded in societal culture and institutions (Parker and Lynn 2002). It considers the complex power dynamics that manifest within race, sexuality differences, gender, and class, which visibly manifest in the lives of people of colour. Grounded in social justice principles, CRT emerged in the mid- to late 1980s as a theoretical movement in US law schools and in critical legal studies. Its application has largely been limited to examining the power structures shaping the marginalisation of people of colour within the United States (Harris 1993). In this context, CRT has been used to understand the historical and sociopolitical roots of present-day health inequalities (Krieger  1987; Gamble  1997; Thomas and Thomas. 1999); examine how the nature of the field may be unintentionally obstructing progress towards equality (King 1997; Bhopal 1998); and elucidate the link between power imbalances inherent in racism and health experiences and outcomes (Brown 2003; Masko 2005; Ford and Airhihenbuwa 2010), as well as access to healthcare (Ford and Airhihenbuwa 2010; Freeman et al. 2017). CRT also illuminates how institutions, such as churches, businesses, families, and health systems, often ‘function based on values, principles, and foundations that are not culturally diverse or representative, irrespective of racial make-up’ (Graham et al. 2011, 85). Accordingly, CRT is helpful in explaining the difficulties that minorities may experience in navigating various institutions and the health inequalities that can persist through subjective bias or privileging of dominant cultural orientations over others. In addition to empirical studies that integrate CRT, there are conceptual works and commentaries that highlight how its application can advance health inequality research

68   Y. R. Shawar and J. P. Ruger (Smedley 2012). Thomas et al. (2011) propose a ‘fourth generation of health equality research’ that is grounded in CRT and tests and develops multilevel interventions that consider the dynamic interplay of the various types of oppression. They provide an example of mixed-methods research that may resolve some of the difficulties of assessing holistic interventions. They argue that CRT principles, including critical approaches, disciplinary self-critique, and the social construction of knowledge, would help highlight how power structures shape health in ways that are invisible to a crude analysis of effects (Smedley and Myers 2014). CRT has been an important means of understanding the role of power in health inequality research in a number of ways. First, it advances narrative as a critical method of inquiry that enables counter-stories of people of colour to be elevated within the context of ‘majoritarian’ master narratives that buttress white privilege; integration of personal narrative ensures that minority voices are heard and not reinterpreted through overanalysis by researchers, which may silence subject communities. Narrative is a valuable approach to research examining power because it enables investigators to discover themes and insights that might not otherwise be recognised or deciphered, given that it is typically a dense and detailed communication of the teller’s life experiences and feelings. Second, CRT supports contextual and historicised analyses, as well as critical analyses of power-infused knowledge production processes. As such, an investigator’s interpretation and analysis of the data collected is informed by the lived experiences of the subjects, as well as by literatures from various disciplines such as cultural studies and history. Third, CRT necessitates investigator self-reflection and reflexive analysis, which make transparent the biases and power dynamics that occur during research processes (Graham et al. 2011). Finally, CRT encourages community-based participatory approaches—linking research, practise, and local communities in order to reflect the priorities, insights, and realities of the individuals who are the subject of the research and thus ultimately being better oriented to take action on addressing health inequalities.

Intersectionality Scholars examining health inequalities have also begun to draw upon intersectionality— a theoretical perspective and methodological lens for conceptualising, analysing, and responding to health inequalities by ‘making visible the fluid and interconnected structures of power that create them’ (Larson et al. 2016). Derived primarily from critical feminist studies and encompassing ideas from the black feminist, indigenous feminist, third-world feminist, queer, and postcolonial literatures, intersectionality was a concept coined by the American sociologist Kimberlé Crenshaw. Her analysis conceptualises the multiple disadvantages experienced by black women, which cannot be accounted for via methods that consider race and gender as distinct categories (Crenshaw 1989). In this way, intersectionality ‘promotes an understanding of human beings as shaped by the interaction of different social locations’ (Larson et al. 2016). This includes gender,

Politics of Global Health Inequalities   69 race, age, sexual identity, education level, ability, religion, and legal status. The interface of these dimensions occurs within environments of connected global processes of power (e.g., globalisation, neo-liberalism) and national and subnational structures of power (e.g., policies, laws, families, media, religious institutions). Through these dynamics, privilege and oppression are produced, influenced also by structures of discrimination, including sexism, racism, colonialism, patriarchy, homophobia, and ableism (Hankivsky et al. 2014). Application of the concept of intersectionality is relatively new in public health, with most of the fifty-three empirical articles published as of 2015 published since 2009 (Larson et al. 2016). Furthermore, its integration is largely limited to scholarship focused on high-income countries, with only a quarter studying intersectionality in LMICs (Larson et al. 2016). Most of these latter studies concern HIV and AIDS, with the main intersectional analysis occurring between gender and economic status or economic status and race, ethnicity, or caste (Larson et al. 2016). Researchers examining health inequalities have applied intersectionality to study the differential experience of ill health and health (Iyer, Sen, and Ostlin 2008; Doyal 2009) and disparities concerning access to and utilisation of healthcare services (Sen and Iyer 2012; Joe 2014; Agénor et al. 2014). Intersectionality has also been applied to examine health inequalities experienced by particular population groups, such as migrants (Suphanchaimat et al. 2015; Alsaba and Kapilashrami 2016; Wickramage et al. 2018), or particular disease areas, such as cardiovascular disease (Wemrell, Mulinari, and Merlo 2017; Wemrell et al. 2016) or HIV and AIDS (Kennedy et al. 2013). In addition, intersectionality has been applied to analyse the differential impacts of health system reforms on particular population groups. For example, McCollum et al. (2019) examine devolution reforms introduced in Kenya in 2013. They find that the reforms insufficiently address the social norms and intersecting power dynamics that support discrimination and marginalisation. This in turn has hindered certain population groups in Kenya from involvement in agenda setting and from accessing and using quality health services. Collectively, these empirical studies go beyond individual social categories, as determinants of health inequality, to the ‘relationships and interactions between such factors, and across multiple levels of society, to determine how health is shaped across population groups and geographical contexts’ (Kapilashrami and Hankivsky  2018). Power structures are central to such analyses, with explicit attention to how various social categories (i.e., gender, ethnicity, class, age, geography, sexual identity) link to, and are impacted by, power-infused socio-historical contexts, systems, and/or processes, including oppression and domination (Hankivsky, Cormier, and De Merich  2009; Hulko  2009). Intersectionality has been applied in both quantitative (e.g., Sen and Iyer 2012; Joe 2014; Agénor et al. 2014) and qualitative studies (e.g., Collins, von Unger, and Armbrister 2008; Kennedy et al. 2013; McCollum et al. 2019). For example, Sen and Iyer (2012), in their quantitative study, draw on household survey data and employ dummy variables to represent intersecting categories of class and gender to explore how certain populations leverage gender advantages or economic class to secure entitlements for treating their long-term illnesses. McCollum et al. (2019), in their qualitative study,

70   Y. R. Shawar and J. P. Ruger employ key informant and in-depth interviews, focus group discussions with community members, and photovoice participatory research with several young people to understand health devolution reform impacts in Kenya. In their ethnographic study, Collins, von Unger, and Armbrister (2008) apply the concept of intersectionality to examine the HIV risk of inner-city women embodying multiple stigmatised statuses. Intersectionality has also been applied in qualitative policy analyses that examine health inequalities (Hankivsky, Cormier, and De Merich 2009; Hankivsky et al. 2014). All of these studies provide a nuanced analysis of power that considers how ‘individuals can simultaneously experience and embody privileges and disadvantage as different social hierarchies combine in varied ways across time and diverse locations’. This is in contrast to viewing a specific social category as ‘uniformly negative’ (Larson et al. 2016). For example, in their analysis of non-poor women in India, Sen and Iyer (2012) find higher rates of non-treatment than amongst men of similar economic standing because of gender discrimination. Poor men in India have the same levels of non-treatment as men of higher economic standing (because poor men can leverage their gender to overcome low economic status). An analysis without an intersectional lens—examining gender or economic status as singular variables—may overlook the interaction of these variables. This can lead to broad interventions for poor populations that do not take account of the particular needs of poor women further disadvantaged by gender (Larson et al. 2016). Such analyses can become even more nuanced as investigators consider additional social locations, such as religion, ethinicity, and ability (Larson et al. 2016). Intersectionality informed analyses provide a more precise mapping of health inequalities, by making apparent not only who is left behind, but also why and how. Ultimately, such studies allow for more effective policy and intervention responses (Kapilashrami and Hankivsky 2018). Intersectionality analysis shares features with health capability analysis. The health capability model assesses individual and societal factors to discover interactive influences, differing from causal, reductionist models in health policy and the medical sciences. Its overlapping circles allow for a more nuanced, sequentially interactive, iterative, and multidimensional understanding of health inequalities. The health capability model is a more flexible analytical approach that reveals greater heterogeneity in the influence of irreducibly social goods on the individual. It incorporates external factors into the individual level rather than trying to draw inferences about individual health based on group- or macro-level characteristics (e.g., race or socio-economic status) alone (Ruger 2010).

Studying Power in Health Inequality: The State of Scholarship The previously described literature as a whole, with its varied conceptualisations of power and location across a number of social sciences, embodies several strengths. First, two major categories of power are investigated in understanding health inequality:

Politics of Global Health Inequalities   71 agency and structural forms of power. Whilst the health inequalities literature generally does not differentiate between agency and structural forms of power, there are distinct approaches and concepts that are applied to study each. Agency forms of power, which are typically more visible, with discernible actor(s) to hold to account for the negative consequences resulting from the power imbalances, are usefully studied via concepts from political science, political economy, and sociology. Structural forms of power, which are typically less detectable and are deeply engrained in institutions, communities, and interactions, are usefully investigated through concepts (i.e., structural violence, structural vulnerabilities, and stigma) and methodologies (ethnography, narrative, active observation, in-depth interviews) from anthropology, critical medical anthropology, and sociology. A second strength of the existing literature is the range of methodologies available to study power and health inequalities. Whilst most studies employ qualitative ­methodologies—drawing on rich data from participant or non-participant observation, written or oral narrative, voice photography, and in-depth interviews and focus groups— there are also increasing efforts to quantitatively investigate power in relation to health inequalities in design and/or analysis, especially amongst researchers applying political economy, and intersectional lenses. Nonetheless, additional methodological tools may be applied to enrich explorations of power. For example, social network analysis may be useful in visualising and quantifying how power is distributed amongst neighbourhoods, as well as amongst health policy networks. Despite these strengths, there are some limitations to the current scholarship. One important challenge is that empirical application of a power lens remains somewhat loose. Power is often not clearly defined and thus measured, and there is little acknow­ ledgement of its mutability (Schaaf et al. 2018). Furthermore, compared to conceptual pieces that discuss power, there are far fewer empirical analyses that rigorously integrate power considerations into their research questions, design, analysis, and discussion of findings. Whilst most empirical studies analysing power as a contributor to health inequality are informed by social science theory, employing measures of social phenomena based on the writings of Lukes, Marx, Engels, Bourdieu, Nye, Goehler, and other political and social theorists, these theoretical foundations are seldom explicitly acknowledged, interrogated, or investigated (Smith and Schrecker  2015). This often results in shallow articulations of power dynamics that exist, with few scholars clearly crystallising how power in their empirical case drives health inequality. A related limitation is that the health inequalities literature insufficiently draws on a more expansive range of power conceptualisations and theories that exist in the social science literature, some of which have been applied to the study of global health or health systems more broadly. More integration of social science theory into health inequality research is needed, allowing for a more robust evidence base and theories about how power and other dynamics affect differential access to healthcare and health outcomes. For example, a good measure of the health inequalities literature explores instances of one actor wielding control (usually derived from material advantage) over another, directly impacting the latter’s health status, health behaviours or choices, and/ or ability to access healthcare. However, few explore the nuances of this kind of power or

72   Y. R. Shawar and J. P. Ruger seek to draw on or expand upon existing social science scholarship. This includes Nye’s (2009) ‘hard power’, which refers to the use of payment and coercion, often via economic or military might, to make others comply; Goehler’s (2000) ‘transitive power’, which concerns one actor overruling the will of another; and Haugaard’s (1997) ‘conflictual power’, which (aligned with Weber, Dahl, and Lukes’s concepts of power) occurs when power is exercised by one actor over another. Similarly, little health inequalities scholarship is situated within existing social science scholarship that sheds light on power exhibited via an actor’s indirect control over another actor’s health experience or access to healthcare via an institution or agent (i.e., organisation or agreement). Whilst some health inequalities scholarship considers ‘institutional power’, few investigators draw on the related concept of ‘dispositional power’, whereby actors are positioned in organisations in relation to each other, and that these positions determine what actors may accomplish (Clegg 1989). Rules and resources typically facilitate this process of positioning. For example, this is observed in the Agreement on Trade-Related Aspects of Intellectual Property Rights-Plus (TRIPS+)— an international legal agreement amongst all the member nations of the World Trade Organization—which has restricted LMIC access to knowledge and medicine whilst benefiting certain multinationals in high-income countries. In the same way, a considerable body of health inequalities literature studies power via stigma, structural violence, or structural vulnerability; however, little of this scholarship considers the related concepts of symbolic and soft power. The former, advanced by Bourdieu (1991), refers to the unconscious form of social or cultural control that is observable in one’s routine social habits. The latter, described by Nye (2009), concerns the ability to co-opt or attract using cultural or economic influence. An additional limitation of this literature is that particular forms of power are far less studied. Whilst this literature considers various agentic and structural forms of power, there is little study of a less visible but potentially more widespread form of power in global health: ‘productive’ (Barnett and Duvall 2005) or ‘epistemic’ power (Shiffman 2014). This type of power is expressed as ‘the socially diffuse production of subjectivity in systems of meaning and signification’ (Barnett and Duvall 2005, 43). Shiffman (2014, 297) interprets this form of power as the way in which meaning is created, ‘particularly through the use of categories that lead us to think about the world in some ways but not others’. This type of power is similar to normative (influence derived from moral authority) and ideological (influence based on the necessity of meaning to social life) power concepts. Gramsci’s (1999) ‘hegemonic power’ is also comparable, referring to the often-unrecognised dominance of particular perspectives that produce agreement amongst groups by making particular social and cultural behaviours the norm, undetectable and therefore unchallenged. This is analogous to ‘non-decision-making power’, which refers to an actor’s ability to determine the topics on an agenda and make particular topics appropriate or inappropriate for consideration (Lukes 1974). More empirical studies of this form of power are especially needed, given that it is one of the least examined and obvious, yet is so critical in shaping health inequality. For example, future research could consider how power is expressed

Politics of Global Health Inequalities   73 in the process of norm creation, adoption, and diffusion, as well as the creation, translation, and communication of knowledge—all of which carry critical implications for understanding and addressing health inequality. Relatedly, certain sources of power are more often studied—in particular, those derived from material or financial sources—to the neglect of others, for example, power that originates from an actor’s political mandate, charisma, moral authority, or technical expertise. Moreover, the literature often does not investigate the simultaneous, multiple sources of power that particular actors hold and express. Rather, there is a tendency to focus on one particular form of power, and often it is the source of power that is most obvious (i.e., the financial power of the Bill and Melinda Gates Foundation), despite other forms of power that are also present (i.e., the foundation’s power derived from its technical expertise). More deeply, the existing literature does little to interrogate the relative importance of agency and structural categories of power, nor does it elucidate the way in which these marked forms of power interact to produce health inequalities. A further limitation of this body of literature concerns the unit of analysis. Typically, scholars investigate cases in which power is expressed or manifested in a way that results in health inequalities. In contrast, minimal studies have looked at instances in which power is used to address, minimise, or eliminate health inequalities. Empirical cases that are positive (an instance in which power is used to improve health equality), and especially those that are surprising (a circumstance in which a less powerful actor is able to resist or overcome a more powerful actor to mitigate health inequalities or achieve improved health equality) are potential interesting avenues of inquiry that would strengthen this body of literature. The current literature often does little to interrogate the seemingly obvious link between power imbalance and health inequalities; the reality is that asymmetries of power are not always predictive of health inequalities and could benefit from additional exploration. Finally, research that studies power as it relates to health inequalities is often not communicated effectively, nor is it appreciated in mainstream global health and global health policy literature. Whilst medical anthropology and sociology and particularly ethnographic research have provided important qualitative contributions to the study of power in global health, as reflected by some of the studies included in this chapter, they still remain ‘off the radar of the global health research community’ (Storeng and Mishra 2014, 859). In particular, anthropologists find it difficult to present their findings to stakeholders within global health so that their findings will be perceived as ‘compelling, timely, and well balanced’ (Pfeiffer and Nitcher 2008). Similarly, intersectionality remains relatively uncommon in epidemiological research. For example, intersectionality is absent in handbooks of measurement of inequality and socio-economic position (Wemrell et al. 2016). Looking to the future, scholars studying health inequalities and power will need to consider how to attract more attention to their research in global health and global health policy circles. This may require them to become more attentive to such stakeholders, political in their advocacy, and ‘sophisticated when “studying up”’ (Pfeiffer and Nitcher 2008).

74   Y. R. Shawar and J. P. Ruger

Ways Forward for Studying and Addressing Health Inequality This chapter concludes by highlighting power frameworks that as of yet have been underutilised in the health inequalities research and study approaches that may be undertaken and expanded for not only study of, but action on, health inequality. Whilst scholars have begun engaging with and broadening the disciplinary base of health inequalities research to the social sciences with deep traditions of thought in the domains of power, as outlined in this chapter, additional analytical frameworks are reviewed. In terms of analytical frameworks, two are highlighted that may be helpful to the study of health inequalities. The power cube framework (Gaventa 2005), derived and mostly used in the field of international development, is useful for simultaneously analysing the levels (local, national, and global places of decision-making and authority), spaces (closed, invited, and claimed arenas for participation and action), and forms of power (visible, hidden, and invisible manifestations) and their interrelationship. The framework may be helpful in examining the interwoven ways in which power drives health inequalities; it also highlights how transformative change around health inequality can only occur in those exceptional instances when movements or actors are able to successfully work across each of the dimensions (levels, spaces, and forms of power) concurrently. The Barnett and Duvall (2005) typology is useful in examining how power is channelled. Specifically, the typology recognises that power works through various social interactions (wielded by an actor over another or through structures and processes that differentially enable and constrain the capacity of an actor to shape its fate) and has varied effects (specific and direct interactions or diffuse and indirect dynamics). Accordingly, the typology describes four concepts of power according to these two analytical dimensions (Barnett and Duvall 2005). Compulsory power refers to ‘the direct control of one actor over the conditions of existence and/or the actions of another’ (i.e., high-income countries exerting control over LMICs via development aid). Institutional power concerns an ‘actors’ indirect control over the conditions of action of socially distant other’ (i.e., the advancement of structural adjustment policies in LMICs by the World Bank and the International Monetary Fund). Structural power refers to ‘the co-constitutive, internal relations of structural positions’ (i.e., refugees’ structural disempowerment is shaped by the stigma they may experience, local and national policies, and their legal status, resulting in healthcare access and health outcome inequalities). Productive power works through ‘diffuse constitutive relations to produce the situated social capacities of actors’ (i.e., who is involved in the research process, the ways data are analysed and interpreted, and the extent to which the findings are accessible have important health equality implications). The typology has been applied to study power dynamics in global health—for example, explaining how states exerted power in the establishment and institutionalisation of the Millennium

Politics of Global Health Inequalities   75 Development Goals (MDGs) (Marten  2019)—and would also be beneficial to an explicit analysis of health inequalities. In addition to deeper and more explicit integration of varied concepts and frameworks to identify and explain power in the study of health inequalities, scholars may reflect and even reconsider how health inequalities research is approached and implemented as an expression of power. First, there is a need for greater scholarly reflexivity, an important approach ‘to naming, acknowledging and addressing/accounting for certain types of power’ (Schaaf et al. 2018). Researchers should observe themselves during the research process, be self-aware of their impact on the individuals and communities they interact with, and reserve space in their publications to detail their reflections on their power and influence throughout the course of their research (Graham et al. 2011). Whilst there is rhetorical acceptance for the need for self-reflexivity, which serves as a critical disciplinary pillar in anthropology and critical studies, it is often not practically applied in a robust way in mainstream health inequality scholarship. There is limited self-reflexivity amongst scholars on how their own social positioning (including the institutions they represent or from which they receive funding) influences the way they approach their research questions and design (Forman 2016) and how their research may even inadvertently contribute to the perpetuation of health inequality. Yet without reflexivity, research may undermine the empowerment scholars often seek to illuminate and advance amongst disadvantaged populations. For example, an analysis that highlights the powerlessness of a certain population can reinforce this group’s sense of stigma, shame, and powerlessness (Smith and Anderson  2018). Without reflexivity, scholars may also perpetuate unhelpful research agendas and global agendas. As Schaaf et al. (2018) note, ‘The dynamics researchers ignore are likely to be similarly absent from the agendas of national and global policy makers. This in turn undermines our ability to understand and address the very power dynamics shaping health disparities.’ Second, future study of power and health inequalities could shift, from only analysing the problem to understanding how research can be a precursor to action to redress inequalities. One way of doing so may be to consider deliberative democratic forms of engagement and/or community-based participatory practises purposefully employed to surmount alienation—especially critical given the power imbalances that typically exist between researchers and the populations they study. More forward looking, researchers may engage in ‘utopia as a method’—a research approach that would necessitate scholars explicitly articulating alternative future scenarios as well as global justice principles in which greater health equity may be realised. Beyond reporting on patterns and causes of health inequality, researchers would work with various communities, particularly those most adversely impacted by health inequalities, to draw up a collective vision for how the community might otherwise be governed; engaging in ‘utopia as method’ may provide the space for such deliberation (Scott-Samuel and Smith 2015). In conclusion, it is a welcome development that study of the role of power in relation to health inequalities has grown substantially. However, this scholarship remains limited in its substantive engagement with the concept of power. Drawing on the varied concepts and methodologies offered by the social sciences, notably from a critical

76   Y. R. Shawar and J. P. Ruger theory perspective, enables scholars to more fully understand the multiple ways in which power dynamics contribute directly and indirectly to health inequalities. The expansion of this academic endeavour, moreover, would form the intellectual basis and inform the policy space for advancing more effective action on reducing health inequalities, which continue to hinder improved global health.

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84   Y. R. Shawar and J. P. Ruger Wemrell, Maria, Shai Mulinari, and Juan Merlo. 2017. ‘Intersectionality and Risk for Ischemic Heart Disease in Sweden: Categorical and Anti-categorical Approaches.’ Social Science & Medicine 177: 213–222. Wickramage, K., L. O. Gostin, E. Friedman, et al. 2018. ‘Missing: Where Are the Migrants in Pandemic Influenza Preparedness Plans?’ Health and Human Rights Journal https://www .hhrjournal.org/2018/05/missing-where-are-the-migrants-in-pandemic-influenza -preparedness-plans. World Health Organization. 2005. Preventing Chronic Diseases: A Vital Investment. WHO; Geneva. World Health Organization. 2017. ‘10 Facts on Health Inequalities and Their Causes.’ http: //www.who.int/features/factfiles/health_inequities/en/ World Health Organization. 2018. ‘Children: Reducing mortality.’ World Health Organization. https://www.who.int/news-room/fact-sheets/detail/children-reducing-mortality World Health Organization. 2019. ‘Social Determinants of Health.’ World Health Organization. http://www.who.int/social_determinants/en/.

chapter 5

Cr itica l A pproach e s to Gl oba l H e a lth Alan Ingram

What does it mean to approach global health critically? To address this question, this chapter situates the critical analysis of global health in a broader intellectual and political context. Its premise is that whilst some conception of critical thinking is inherent to the creation of any systematic knowledge about the world, thinking critically also means taking power and politics into account; to approach global health critically is to appreciate that any analysis of global health takes place in the midst of power relations, power struggles, and political events. This is not to say that the world and knowledge about it are entirely determined by the distribution and deployment of power, or that everything can be reduced to politics. A belief that ‘everything is political’ does not entail the idea that ‘politics is everything’. The point is rather that any attempt to understand the world (or more specifically, global health) without some awareness of how this enterprise is enabled, constrained, and oriented by power relations, power struggles, and political events will in some sense be uncritical and therefore lacking. The chapter is itself critical in that it adopts a questioning approach towards the problem at hand and recognises that the question of what counts as a ‘critical’ approach to global health is contested and contestable. Whilst recognising that some approaches have been influential and indeed formative for critical thinking on global health, it aims to prompt reflection about the meaning of criticality (or critique), as well as the possible stakes and pitfalls of being critical in particular ways. In pursuit of this goal, the chapter is organised in four main sections. The first section offers a brief genealogy of critical thinking in global health in relation to the European Enlightenment and critiques of it. The second section identifies three sources of critical thinking in global health. The third then considers in more detail some of the more influential critical approaches to global health, covering critiques of political economy, representation, and biopower. The fourth, concluding section offers some challenges for critical thinking in global health by considering debates on the fate of the critical enterprise itself.

86   Alan Ingram

A Brief Genealogy of Critical Thinking The global health field as it exists today can be thought of as having emerged in the wake of the Enlightenment, the intellectual movement that developed in Europe in the seventeenth and eighteenth centuries. In broad terms, this movement sought the progressive elimination of suffering, want, and oppression and the enhancement of freedom via the application of reason and rationality to human affairs. Global health can therefore be understood as a critical project to the extent that it embodies these ideals. However, whilst it might appear to be self-evidently progressive, the Enlightenment project has itself come to be viewed much more critically in light of its apparent implication in the horrors of colonialism, two world wars, and the Cold War. As many thinkers have observed, the pursuit of progress through reason is tangled up with the exercise of power, and, as discussed in this chapter, the ostensibly progressive intentions characteristic of the global health field have themselves been subject to critical appraisal. The work of Immanuel Kant is fundamental to the Enlightenment understanding of critical thinking. As Kant wrote in a footnote in the preface to the first edition of the Critique of Pure Reason ([1781] 1933, 9, note a): ‘Our age is, in especial degree, the age of criticism, and to criticism everything must submit. Religion through its sanctity, and law-giving through its majesty, may seek to exempt themselves from it. But then they awaken just suspicion, and cannot claim the sincere respect which reason accords only to that which has been able to sustain the test of free and open examination’. For Kant, criticism meant subjecting matters to systematic questioning and reasoning in an open and public way; any authority that claims exemption from such scrutiny is thereby not worthy of ‘sincere respect’. Critical thinking can thus be thought of as being fundamental to both modern scientific activity and modern ideas of rights, democracy, freedom, and the public sphere. In the essay What Is Enlightenment, Kant ([1784] 2009, 1) urged, ‘Sapere aude!’: dare to know! Enlightenment is the emergence from dependence on authority, achieved through the exercise of systematic, rigorous, and reflective thought and inquiry. Though such ideas might seem to be self-evidently progressive, the scope and implications of the Enlightenment have always been contested. Whilst the import of Enlightenment ideals is ostensibly universal, many European thinkers held that ­freedom and equality could only be extended to sufficiently capable and responsible subjects, who were invariably understood to be property-owning men of Western European heritage. Liberal thinkers often thought that ‘civilised’ and ‘uncivilised’ populations would have to be governed in fundamentally different ways: whilst the civilised could exercise reason, freedom, and equality in a responsible way, paternalistic or harsh measures would always be required for others, whose best interests would be decided for them (Duffield 2007).

Critical Approaches to Global Health   87 To what extent are the critical ideals of the Enlightenment universal, or universalisable, then? This is a significant question for a field that calls itself global health. For many anticolonial thinkers, the Enlightenment is fundamentally compromised by its historical association with European domination. For Frantz Fanon ([1963] 1991), a trained psychiatrist and theorist of anticolonial revolution, rationality was always on the side of the colonisers; by comparison the colonised would always be seen as fundamentally different and inferior. Feminist thinkers since Mary Wollstonecraft ([1792] 1992) have questioned the masculine bias of European critical thought, whilst socialist thinkers before Karl Marx and since have questioned whether true knowledge or freedom is possible within a capitalist system. At the same time, such critiques have often themselves been advanced via rational argument and debate and in the name of universal ideals (Israel 2001). Whilst framed by Enlightenment ideals, the global health field can be thought of more specifically as having inherited what anthropologist Tanya Murray Li (2007) has called the ‘will to improve’. As Li argues, ‘improvement’ has frequently, if not invariably, meant actions taken by some people to ameliorate the lot of others, a process that involves values (which may not be shared) and which is necessarily relational (because it implies distinct roles of knowers and known, improvers and improved). Improvement is thus fraught with issues of control: Who sets the agenda and who is in charge of implementation? The relational dynamic between improvers and those-to-be-improved, Li suggests, began in the colonial era but endures in contemporary development and humanitarianism and is liable to affect any project, regardless of the intentions of the improvers. No matter how benevolent these might be, Li argues, problems arise when improvement is led by outsiders. The idea that such problems can be avoided via ­participation and partnership has itself been subject to critical appraisal: How meaningful can such processes be across huge gaps in wealth, knowledge and power (Cooke and Kothari 2001)? If today’s ideas of improvement are descended from the colonial period, they were reshaped during the Cold War and decolonisation. Whilst the Western and Soviet blocs advanced distinct models of health and development based on their respective systems and ideologies, the non-aligned movement tried to develop alternative paths. Ensuing struggles affected the workings of the World Health Organization (WHO) and other United Nations (UN) bodies and pervaded health policy debates, for example that surrounding the primary healthcare movement that was launched at a meeting in AlmaAta in the Soviet republic of Kazakhstan in 1977 (Lee 2009). Consider also the efforts by the post-revolutionary Cuban state to project its influence by exporting doctors and nurses as well as soldiers across the ‘Third World’ (Kirk 2015). Western states likewise often saw the provision of healthcare as a way of projecting influence and developing political relationships in an ostensibly non-political way. The project of improvement also flourished within individual nation-states, especially in the political context of decolonisation following the end of World War II. Competing national projects across ‘first’, ‘second’, and ‘third’ worlds sought to link health programmes with competing ideas of identity, progress, and modernity, which

88   Alan Ingram were sometimes also associated with regional identities like pan-Africanism, panArabism, and pan-Americanism. Ideas of national and regional identity combined with distinct ideas of gender and household structure: to be a healthy citizen of a nation invariably meant contributing to its growth, development, and flourishing in particular ways, for example by giving birth to a certain number of children and raising them in line with ideas of the public good. Ideas about health were therefore fundamental to ideologies of development, and the extent of a country’s success in, for example, vaccination programmes, extending public infrastructure, or improving nutrition and education came to be seen as indicators of political success. Today’s global health field has emerged in large part out of the crisis of these models of health, development, and progress, and amidst the growing influence of ‘neo-liberal’ ideas and policies, according to which state and society ought to be re-engineered in terms of private economic interests (Harvey 2005). Emerging during the 1970s, these ideas have increasingly affected health and health policy around the world. In 1982 interest rate increases by banks based in the global North triggered debt crises across many countries that had borrowed to finance development in the 1960s and 1970s. In return for bailing them out, the International Monetary Fund (IMF) and World Bank, backed by governments in the global North, sought to shrink the public sector and expand the private. Public health services were defunded; across much of sub-Saharan Africa, Latin America, and South Asia, and with increasing speed across post-communist countries after 1989, many standard indicators of health and development went into reverse. ‘Old’ diseases like cholera, malaria, and tuberculosis made a comeback, and ‘new’ diseases, most notably HIV, emerged, in a world that was becoming ever more connected. The models credited with producing health and wealth for some seemed to entail the opposite for others. In this context, the idea that health had to be understood in ‘global’ rather than ‘international’ terms began to gain ground amongst policy communities as well as academics (Brown, Cueto, and Fee 2006). Influential here was the work of journalist Laurie Garrett (1995, 2000), who diagnosed the global health problems of the 1990s primarily in terms of a lack of political awareness and responsibility. Focusing on the problem of emerging infectious diseases, she argued that governments and political leaders had largely failed to give health issues adequate priority and had failed in their duty to ensure the provision of adequate health infrastructures and services. In light of globalisation, policymakers had to give new priority to health and ought to consider it a security issue alongside defence and strategic policy. Though telling, Garrett’s account remained rather circumscribed in terms of its analysis of power and politics. A contrast can be drawn with the work of anthropologist and physician Paul Farmer (1999, 2003), which illustrates more fully what critical thinking in global health has come to mean. For Farmer, the policy shifts of the 1980s and 1990s emerged from, and served to exacerbate, long-term, deep-seated patterns of racial oppression, political disempowerment, and economic disenfranchisement. Here Farmer’s work is exemplary in challenging narrow framings of global health problems and advancing fundamental criticism of the social, economic, cultural, and political relationships in the midst of which they emerge.

Critical Approaches to Global Health   89

Critical Thinking in Global Health Where does the impetus for critical thinking in global health come from? On one level we can again refer to Enlightenment ideals of improvement, freedom, and justice. But we can also think a bit more deeply about how critical thought emerges out of epidemiological events and the expertise they engender, out of distinct epistemic or research communities, and out of social and political struggles. First, critical thinking is occasioned by the attempt to make sense of disruptive ­epidemiological events. Historians and philosophers (e.g., Latour 1988; Foucault 2007) have considered the processes whereby, in the modern period, epidemics have driven innovation and experimentation in economic and political thought as well as medicine and public health. An important example of this in recent history is the way in which HIV epidemics around the world gave rise to new fields of scientific inquiry and debate, beginning with the race to characterise HIV and to develop new treatments and interventions, a process that has carried with it profound social, cultural, and political implications and ramifications (Piot 2015). Research into pandemic influenza has similarly given rise to wide-ranging and hotly contested debates about appropriate surveillance and response mechanisms and over vaccines and antiviral medications should be developed and distributed (Fidler 2010). As these examples indicate, the social, cultural, and political reception of an epidemiological event as an event is shaped by contending forms of expert knowledge, which can transform the ways in which something is understood as being a health problem and an epidemic in need of response. A particularly clear example of this is the way in which tobacco came to be framed as a public health issue, a process that involved a wholesale redefinition of smoking as a problem and tobacco companies and governments as responsible actors (Collin, Lee, and Bissell 2002). Events are thus not entirely straightforward: our sense of events as events depends to some extent on the forms of knowledge and expertise that frame them. Second, critical approaches to global health have emerged in particular epistemic communities—that is, within specific networks of research, critique, and debate that have tended to construct knowledge in particular ways. The disciplinary tradition of anthropology, for example, tends to emphasise the importance of everyday, non-elite knowledge, whereas the field of international relations has traditionally focused on how actions and agendas on a global scale are shaped by states and other institutions. Much knowledge is generated within, or in close proximity to, policymaking bodies, such as research by the World Bank that helped to redefine tobacco as an economic as well as health problem (World Bank 1999; Shibuya et al. 2003), but sometimes thinking is more closely connected with social movements, such as the access to medicines (ATM) movement (Smith and Siplon 2006). Some strands of research are more heuristic and others more theoretical; some are more applied and others more reflective. The body of critical thinking on global health also to some extent reflects the geography of knowledge production more generally, in often being centred around global North languages, theories,

90   Alan Ingram and institutions. However, none of these communities is entirely hermetic, and the formation of coalitions across epistemic communities, as in the case of the anti-tobacco movement and AIDS activism, can itself be understood as a source of new critical perspectives that can influence global health thinking, policy, and practice. Third, some of the main critical approaches that have been brought to bear on global health have been forged in the context of broader social and political struggles, Whilst struggles over global health have themselves also engendered new thinking. As we have seen, the critical philosophy of the Enlightenment emerged in part as a struggle against religious and monarchical authority; similarly, critical theories of economics were shaped by the struggles of working people, feminist theories emerged from struggles against patriarchy, and critical theories of race came from anti-racist struggles. One locus of particular importance for the social sciences and humanities in the global North has been the intense intellectual, social, cultural, and political ferment of the late 1960s and early 1970s, which saw the emergence of ‘new’ social movements associated with identity, gender, sexuality, human rights, and the environment, as well as the rethinking of ‘old’ movements centred on critiques of capitalism, colonialism, and militarism. This period also saw significant shifts in the theory and practice of development and humanitarianism, Whilst the debt and financial crises of the 1980s and 1990s and struggles over the AIDS crisis each produced distinct episodes of concentrated critical thought. Critical approaches to global health are not purely theoretical exercises, then, but emerge out of messy collisions amongst epidemiological events, scientific debates, and broader social and political struggles, which their proponents are in turn often attempting to influence.

Varieties of Critique It is further possible to disentangle different varieties of critique in global health. At one level we can identify critique as an inherent facet of intellectual inquiry, in that it means subjecting any account of the world to systematic questioning and scrutiny. Many studies use analytical tools to scrutinise how power, politics, and policy affect both health outcomes worldwide and the institutional field of global health governance. One influential reference point has been the ‘health policy triangle’ advanced by Gill Walt and Lucy Gilson (1994), which enables analysts to unpack instances of health policymaking in terms of the contexts, actors, and processes at work, then to identify different kinds of power that may be in play in a given situation (Gilson et al. 2008). Such heuristic (or descriptive-interpretive) approaches are useful in that they can quickly enable people to begin thinking about power and influence in global health, Whilst indicating where further investigation might be useful. A further example of systematic, questioning analysis is the work of David Fidler (e.g., 2008, 2010) on the politics of epidemics, global health diplomacy, and global health security. Fidler’s work shows how, despite attempts to build global health surveillance

Critical Approaches to Global Health   91 and response systems to deal with emerging infectious diseases since the 1990s, the politics of epidemic response has still been strongly driven by how the more powerful states in the global North define and pursue their national security interests. In the midst of the H1N1 pandemic of 2009, the richer and more powerful states, prioritising the protection of their own populations, were able to effectively monopolise the antiviral drug and vaccine supply until concerns about the event had abated (Fidler 2010). By putting together a timeline of the event, Fidler questions and qualifies statements by states to the effect that they were committed to global cooperation and sharing of resources, in effect holding them to public account. In conceptual terms this work implicitly brings a ‘realist’ approach to bear on the international politics of health, whereby the workings of global health are shown to be primarily still driven at the state level, by material interests and by concerns about exercising sovereignty, or ultimate decision-making, in a given situation. This analysis suggests that revision is needed of earlier views of global health as having made the transition to a new, more enlightened form of governance appropriate to the global era. Fidler’s work thus points to the limits of progress and to how deeply rooted political factors continue to influence what is possible in global health. We can also identify more self-consciously critical varieties of thought, such as ‘Critical Theory’. This term properly refers to a specific form of analysis developed by the influential post-war ‘Frankfurt School’ of social analysis but is also often employed (without the capital letters) to include theories claiming allegiance with social movements seeking emancipation or freedom from domination. The Frankfurt School developed a form of Marxist analysis that was critical of capitalism but also of the state communism maintained by the Soviet Union and its allies, and further embodied a critical stance towards the Enlightenment itself. Its leading theorists, Theodor Adorno and Max Horkheimer ([1947] 1997), argued that the Enlightenment had to be rethought in quite fundamental ways after World War II and the Holocaust, but also in light of what they saw as the banality of Western culture and institutional life. As they saw it, the progressive rationalisation of human affairs according to science and reason ­necessarily resulted in disenchantment and barbarism. These downsides were not external to Enlightenment rationality but were produced by it, as they thought, ‘dialectically’. Ideas and ideologies of freedom, progress, and improvement could not therefore be taken at face value and had to be subject to continual critical scrutiny. Critical theory has played a significant role in global health debates since the 1990s, and in the following I trace its influence as well as ensuing debates and developments in three stages.

The Critique of Political Economy During the 1980s and 1990s neo-liberal theorists tended to promise and predict that their version of globalisation would spread prosperity, reduce conflict, and enhance health, Whilst any downsides would be due to faulty or partial implementation rather than the theories themselves (for an expression of this see Feachem 2001). By contrast, more

92   Alan Ingram critical analyses insisted that these downsides were indeed inherent to ‘neo-liberalisation’ (Navarro 2007). A central task of critical analysis here has been to expose what is held to be the ideological (i.e., false and biased) nature of dominant ideas. The thought of the Italian communist Antonio Gramsci has been influential in this regard. Gramsci (1971) analysed the political situation of early twentieth-century Italy and came to the conclusion that part of the reason that communist revolutions had not been successful was that certain sectors of society that might have been expected to rally to the communist cause had embraced ideas that ultimately served the capitalist class. Dominant sectors of society had insulated themselves politically by propagating capital friendly ideas throughout society, in culture as well as in politics and economics, endowing an unequal society with undeserved legitimacy. The continuation of capitalism was thus secured not just by coercion but also by the production of consent. This could be achieved by establishing certain patterns of thought as unquestionable ‘common sense’. The struggle for a better society would accordingly include the attempt to shift common sense to a position friendly towards what was held to be genuine social progress. The battle of ideas was as important as practical organisation, and if revolution was not possible, it was still important to fight to establish an understanding of the situation that was correct from a critical point of view. This would enhance the prospects for revolutionary change should the political situation shift. This background enables us to understand why many critical theorists considered neo-liberal ideas of globalisation to have become ‘hegemonic’—that is, to have achieved the status of ‘common sense’, from which all (or most) would benefit and only the deluded or deficient would dissent. A large part of critical global health analysis during the 1990s and since (e.g., Thomas and Weber 2004; Navarro 2007) has accordingly been concerned to expose and challenge these ideas by showing how neo-liberal policies have been implicated in health crises and how this has stemmed from the dominant role played by the IMF, World Bank, and World Trade Organization (WTO) in global health policy. Much critical global health analysis has therefore been engaged in what Marx (1859) called the ‘critique of political economy’, of dominant ideas of politics and economics. Some analysts have further linked this critique with others, for example, linking feminist and political-economic critiques of international responses to HIV/AIDS (O’Manique 2005) or interpreting new epidemic alert and response systems as in some sense neocolonial, to the extent that they involve the projection of ideas and technologies developed in the global North into other areas of the world (Weir and Mykhalovskiy 2007). Such critiques promote ideas of emancipation from domination and typically call for more democratic structures and processes within global politics. If Critical Theory approaches to global health gained ground amidst the struggles of the 1990s, the theoretical landscape has to some extent shifted since then in tandem with changes in the global health field. Around the year 2000, a combination of social movement mobilisations, critical academic analysis, and scientific and political alarm contributed to major shifts in global health governance. Donor states began to pledge increasing amounts of overseas development aid (ODA) for health (albeit targeted towards a highly selective range of problems). After having been largely sidelined in

Critical Approaches to Global Health   93 the 1980s, WHO assumed a more active and political role in global health policy debates under Gro Harlem Brundtland. A broader range of corporate and civil society actors began to get involved in global health, often but not exclusively around the response to HIV/AIDS. And new institutional forms, such as the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria (the Global Fund), were created. Such ‘global health partnerships’ typically assembled some mix of government, corporate, civil society, and academic actors to work together in new ways to find solutions to global health problems. Global health problems were being addressed, or ‘governed’, in apparently novel ways. The implications of these developments have been the subject of extensive critical debate. On the one hand, for example, new philanthropic initiatives seemed to offset the case made during the 1990s that the rich and powerful had abandoned responsibility for those less fortunate. But Whilst some new money has been allocated to global health and development, and a degree of progress has been achieved in certain areas such as the responses to HIV and malaria, the kinds of global health interventions that have emerged since 2000 carry ambiguous implications. In terms of critical theory, the key question is whether these new developments represent a radical transformation of global health or incremental (or even possibly counterproductive) reform.

Debating Product (RED) Many of the issues surrounding the new global health initiatives that emerged during the 2000s were crystallised in a debate concerning the implications of the (RED) project, an initiative led by celebrities and large corporations to generate revenue for the Global Fund, a new but controversial funding mechanism created in 2001. (RED) has contributed hundreds of millions of dollars to the Global Fund, but this is only a small percentage of its multi-billion-dollar programme, which is largely funded by governments, and which is in turn only a percentage of what is needed to address HIV in full. What, then, is the significance of (RED)? In a critical analysis, Colleen O’Manique and Ron Labonte (2005) effectively argued that its real significance was ideological, in that it seemed to demonstrate that corporations and consumerism could help to solve global health problems. They suggested that large corporations, many of which had been criticised for unethical and exploitative practices during the 1990s, were effectively using the initiative to project an image that was contrary to reality: rather than being part of the solution, such corporations were drivers of a form of neo-liberal globalisation that was in fact inimical to global health. The real effect of (RED) was thus to perpetuate an existing state of affairs and block the formation of critical awareness. Responding to this critique, Jeremy Youde (2009) argued that rather than preventing people from forming an appropriate critical understanding of the role of corporations in global health, (RED) might actually form an entry point for greater awareness and participation, Whilst generating additional resources that global health activists could ill afford to disdain.

94   Alan Ingram This exchange can be placed more broadly in the context of critical takes on ‘philanthrocapitalism’, ‘charitainment’, and ‘celebrity colonialism’ (see the chapter in this volume by Youde), each of which, critics have argued, is a shallow, ideologically laden, and limited response to profound structural problems in the way the world works. If critical theories tell us that capitalism and colonialism continue to influence the world in deep, consequential, and harmful ways, so the critical reasoning goes, only deep and radical change will suffice to address the problem; furthermore, this cannot be delivered by entities that have a vested interest in maintaining the existing state of affairs. Whilst philanthropic ventures have dramatically altered the global health landscape in the last couple of decades, a critical theory take might suggest that this has come about by focusing on technical interventions rather than on political or structural change; by substituting private, discretionary decision-making for public, democratic accountability; and by validating corporate domination of the global economy so long as the wealth it generates is later given away. Whilst noting the real benefits to people of philanthropic giving, from a critical theory perspective this would nevertheless amount to an adjustment or even entrenchment of a global order that is still fundamentally unjust.

The Critique of Representation Whilst such debates have been taking place, research has also explored how global health politics is shaped by what has been called the politics of representation. The argument is that how people represent the world to themselves and each other has important consequences for what happens in the world. A central point here is that prejudicial stereotypes about other people and places help to make and sustain unequal power relationships; our ideas and images of the world do not simply reflect a preexisting, material reality, but help to bring that reality about. This line of thinking also implies a potential remedy: perhaps we can change the world by representing it differently. A clear example of this is work towards the destigmatisation of people living with HIV, to which the effort to shift language and imagery has been central. This line of thinking has been particularly influential in international relations (IR) work on global health, which has examined what IR theorists call ‘securitisation’ (Buzan et al 1998; Balzacq 2011). The underlying thrust of securitisation theory is that saying something is ‘a security issue’ is more than a description; it also sounds the alarm and calls for action. Because governments consider security their overriding priority, so the reasoning goes, getting a problem recognised as a ‘security issue’ can lead to its increased prioritisation. The clearest example of this seeming to work is in relation to HIV/AIDS, which the US government and the United Nations accepted as a security issue around the year 2000, thereby adding force to international responses (Elbe 2006,  2010; McInnes and Rushton 2010). Securitisation theory counts as a critical theory in three ways. First, it helps us to think about power and politics: for a securitising speech act to be successful, it must be made by a figure with authority; that is, the security ‘speech act’

Critical Approaches to Global Health   95 requires some form of political power in order to be successful. Second, it encourages reflection on the potential downsides of political ‘success’: securitisation theorists highlight that there are many dangers to invoking ‘security’, especially where this leads to normal political processes being suspended or bypassed (theorists have also debated how far the theory applies in situations where exceptional powers are the norm). Third, securitisation theory reminds us that just changing our representations is not enough on its own; we need to think about how language connects to other forms of power.

The Critique of Biopower As the purchase of communist ideas on world politics was eroded during the 1990s and 2000s, the idea that a broadly Marxist account of the world could, more or less directly, inform the practice of socialist and revolutionary movements to create a better world was intensely questioned across the political and intellectual Right and Left. There are many strands to this debate, but two are particularly relevant here. One is that the major ‘Critical’ theories have had a narrow view of what counts as politics (social movements enacting revolutions or taking control of the state); the other is that such theories, in claiming privileged insight into how the world works and how it should change, have themselves become undemocratic, lapsing into a kind of policing exercise over what ‘criticality’ ‘really’ means. Conversely, theorists tagged as being ‘post-critical’ have been criticised for failing to confront domination in a direct enough way and have thereby been held to be complicit with it. A central figure in these debates has been Michel Foucault, a French thinker who challenged disciplinary boundaries (he might be considered variously as a historian, a philosopher, an ethicist, or a political theorist) and who has become the most influential and most debated critical intellectual of the last forty years. He is important to consider here first because he saw himself as revisiting and critically extending Kant’s idea of Enlightenment (Foucault 2000) and second because health and disease were central to his seminal idea of ‘biopower’ (Foucault 2007). Foucault argued that Whilst Marxist thinkers had become overly preoccupied with the economic determinants of politics, political theory was fixated on the figure of the sovereign ruler who commanded the state. What they both missed, he suggested, was biopower: the means whereby the management of living things became the object of political strategy, or ‘governmentality’. Foucault argued that power was exercised not only through sovereign power or by controlling the means of production, but also by myriad techniques for managing individuals, groups, and populations. Biopower was at work in the training of soldiers, the reform of prisoners, and the enhancement of worker productivity; in the management of food shortages, epidemics, and crime; and in architecture and urban design. Whilst the centralised sovereign power of the state could be brought to bear in times of war or to colonise other people and places, biopower often appeared as a positive force, concerned with the enhancement of human potential and exercising control in subtle and indirect ways.

96   Alan Ingram Foucault’s thought has been politically controversial on the left because of his emphasis on the dispersed nature of power and hence the importance of local struggles, rather than centralised political movements aimed at taking control of the state or overthrowing capitalism. He also expressed a certain modesty about his work, encouraging others to view it as offering tools that they might or might not take up or adapt in their own struggles, rather than, as some Marxists claimed, a ‘scientific’ route map to universal human emancipation. Other controversial aspects of his work include his interpretation of truth as a political construct; Whilst some people struggling for liberation and equality have found such thinking enabling, others are concerned that if fundamental ethical and political ideas are seen as malleable, this leaves no solid ground upon which to stand and make claims. Foucault’s influence on critical approaches to global health is evident in the widespread use of his concepts—including biopolitics, discipline, and governmentality—across disciplinary fields, including history (Bashford 2006), anthropology (Zigon 2010), international relations (Elbe 2005), sociology (Kenny 2015), and geography (Brown, Craddock, and Ingram 2012). Indeed, the emergence of the in­ter­dis­ci­pli­nary field of critical global health studies is in significant ­measure attributable to the influence of his ideas.

The Stakes of Critique This concluding section considers the relevance of ongoing debates on the wider stakes of critique for the field of global health, thereby offering reference points for further reflection. One criticism of critical theory is that it is always seeking to unveil, reveal, or expose something that we supposedly cannot otherwise perceive. A useful starting point here is the philosopher Paul Ricoeur’s (1970, 33) description of Marx, Friedrich Nietzsche, and Sigmund Freud as ‘masters of suspicion’. As Ricoeur observes, Whilst they advanced very different ideas, each of these thinkers proposed to expose what he saw as the false nature of consciousness and to reveal how our sense of the world is actually determined by something else, whether this be (respectively) the mode of production, the will to power, or the unconscious. According to these theorists, our understanding of the world and ourselves is always false and needs to be exposed as such in order for real understanding and emancipation to become possible. A simplified parallel of this narrative in global health might be the (in critical terms, ideologically misled) consumer who buys a (RED) iPod, incorrectly believing themselves to be helping to end the AIDS epidemic. If consumers could only break the ‘commodity fetish’ and gain critical knowledge and awareness (e.g., that concerted governmental action is a primary solution and that corporations should be taxed and regulated rather than celebrated and empowered), they might then be in a position to transform themselves and the world. The literary theorist Rita Felski uses Ricoeur’s idea of suspicion as a starting point for enumerating the main elements of critique as an academic activity. As she notes, ‘critique is negative’: ‘To engage in critique is to grapple with the oversights, omissions,

Critical Approaches to Global Health   97 contradictions, insufficiencies or evasions in the object one is analysing’ (Felski 2012). Critique is therefore secondary to the thing that is being critiqued; it is also a second order or meta-level activity and thus, it would seem, inherently ‘intellectual’. A further aspect of critique is its relationship to politics: the academic critic may ally with social movements but typically maintains a certain distance from them and reserves the right to adopt a critical stance towards any particular political manifestation of the critical project. Critique is also inescapable in that within the critical universe there are no (desirable) alternatives to it; if one is not critical, one can only be uncritical (a bad thing). For Kant, critique offered a means of creating knowledge independent of religious and governmental authorities and of submitting their claims to the test of reason. For the Frankfurt School, the critical attitude was a kind of least-worst option in a world where the promise of the Enlightenment had given rise to disenchantment and barbarism. And for many theorists, critical theory promises a way to diagnose the problems of the world but also a route map or toolkit for fixing them. However, some thinkers have in recent years suggested that the critical project has itself run into deep problems. The philosopher Jacques Rancière (2009), for example, has written about what he calls the ‘misadventures of critical thought’ with particular reference to the French intellectual and political scene. He has argued that ordinary people do not need ‘critical’ intellectuals to explain the nature of their domination to them. Critical understandings of the world are widely shared, and ‘critique’ has become a self-serving and self-referential genre, with hackneyed dramas of exposure, revelation, and enlightenment standing in for actual, progressive change. In a somewhat related vein, Bruno Latour (2004), another French intellectual, has suggested that critique has ‘run out of steam’. Critical theory, Latour argues, has become a predictable schema that one can apply to any situation to produce reliable results, with the added bonus of placing the critic in the central, heroic role of ‘unveiling’ and ‘challenging’ oppression. What particularly concerns Latour, however, is the way in which deconstructive approaches to science and truth of the kind he pioneered have apparently been turned against climate science by those hostile to its findings. If politicians and commentators have condemned critical academics for their relativistic approach to truth as in some sense fabricated, they have also realised that this schema can be applied to relativise the work of academics themselves: ‘climate change’ research could be portrayed as a self-interested industry; similarly, in global health ‘anticolonial’ politicians have dismissed antiretroviral therapies as a ‘neocolonial’ ruse. In the wake of critical theory, Latour suggests, the fostering of doubt, scepticism, and suspicion has become a political technique in the service of vested interests, with dangerous consequences. Where does this leave us, if all knowledge can be dismissed as a product of bad faith and self-interest? Latour’s answer is that academic communities need to realise that they are in a war over knowledge and to take on the challenge of demonstrating that some accounts of the world are indeed better than others. This idea will be far from surprising for many working in the global health field, who have first-hand insight into how to wage such wars (critical thinkers have debated whether the war metaphor is a good one; Bleakley 2017). Latour and Rancière have furthermore been criticised for what is seen as

98   Alan Ingram the superficiality of their analysis (Wark 2017; Foster 2012, respectively). The question of what makes an approach ‘critical’ therefore turns out to have profound implications for global health politics and research. What is at stake is, first, our understanding of the nature of reality (ontology); second, the means whereby we can generate effective knowledge of that reality (epistemology); and third, what we would do on the basis of that knowledge (practice, or, to use the critical philosophical term, praxis). To approach global health critically means taking on such issues in light of the developments, struggles, and debates considered here.

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pa rt I I

GL OBA L H E A LT H A N D T H E W I DE R P OL IC Y AGE N DA

chapter 6

Gl oba l H e a lth Dipl om acy Akram Khazatzadeh-Mahani, Arne Ruckert, and Ronald LabontÉ

Health issues have received unprecedented attention and prominence in global policy negotiations over the last two decades (Fidler 2016), featuring in national and global security strategies and finding their way onto the meeting agendas of leading economic powers and key bilateral and multilateral institutions and negotiation processes. One manifestation of this policy ascendency has been political agreements and treaties between and among nations predominantly driven by health concerns, such as the Framework Convention on Tobacco Control (FCTC). These developments have reversed the historical position of health in foreign policy as a mere humanitarian issue (Fidler and Drager 2006), as globalization’s accelerated pace of international economic interdependencies has blurred the boundaries between domestic and foreign health policy agendas (Owen and Roberts 2005). Examples of how health concerns have entered the realm of foreign policy and penetrated the global political agenda are abundant. The outbreak of severe acute respiratory syndrome (SARS) in 2003 and the H1N1 influenza A pandemic in 2009 demonstrated how infections can spread rapidly across the globe, affecting traditional foreign policy concerns of travel and trade. SARS also highlighted the urgency of negotiating reforms to the International Health Regulations (IHRs) and emphasized the need to develop better forms of global cooperation to control disease outbreaks (Owen and Roberts 2005). Global health challenges such as the HIV/AIDS pandemic, the 2014 Ebola outbreak in West Africa, the spread of Zika virus to the Americas, and bioterrorism are all seen as direct threats to national security and foreign policy interests because of their ability to threaten international stability (Elbe 2006; Feldbaum 2009; Michaud and Kates 2013). Finally, critical attention has focused on the proliferation of comprehensive regional trade agreements and how these might indirectly affect health outcomes (Fidler and Drager 2006; Ruckert et al. 2017).

104   Akram Khazatzadeh-Mahani et al. These challenges, the pressing need to address growing global health disparities, and the recent calls for multi-actor and multi-sector collaborations in the sustainable development goal process (Bali and Taaffe 2017; Faid 2012) have contributed to a growing consideration of the intersection among global health, foreign policy, and diplomacy (Michaud and Kates 2013). This has led to renewed interest in developing legal instruments and agreements between nations that match increased commitments at the global level to public health surveillance and response (Katz et al. 2011). Such developments together have resulted in new forms of global health governance and diplomatic processes, often referred to as ‘global health diplomacy’ (Runnels, Labonté, and Ruckert 2014). In this chapter we first define global health diplomacy (GHD) and discuss its origins. We next explore how health and foreign policy have become linked and how they interact in GHD processes. After that we describe how GHD can function as a ‘soft power’ tool and elaborate on diverse GHD instruments. Finally, we discuss how and why health issues reach the political agendas of foreign ministries. The chapter concludes with a discussion of how to evaluate and improve GHD processes and raises some research questions about how to further advance the academic study of GHD and why it remains an important area for scholarly scrutiny.

Global Health Diplomacy: Definition and Origins Global health has developed into an area of study distinct from international health. The latter term captures international cooperation on high disease burdens and inadequate health systems in developing countries, emphasizing issues such as access to healthcare, disease prevention programs, and medical treatments. Global health, in contrast, deals with health issues that transcend national boundaries in cause and consequence and places a normative priority on achieving health equity worldwide, sharing with international health an emphasis on improving the health of vulnerable populations (Koplan et al. 2009). The term ‘diplomacy’ has a long pedigree, its modern meaning having been popularized by Edmund Burke in 1796. Defined simply, it refers to the negotiations among officials of various countries to reach their disparate foreign policy objectives without having to resort to war (Kickbusch et al. 2012). In practice, diplomacy can exercise ‘hard power’ (economic sanctions and military operations), ‘soft power’ (co-option and cooperation), or more likely both hard and soft power combined in ‘smart power,’ using various modalities and actors to achieve foreign policy goals (Novotny and Kevany 2013; Nye 2004). Global health diplomacy (GHD), a merger of the two concepts global health and diplomacy, is a more recent term and has been defined as the multilevel and multi-actor negotiations that shape the global policy environment for health (Drager and Fidler 2007; Kickbusch, Silberschmidt, and Buss 2007). This includes the

Global Health Diplomacy   105 various ‘processes through which States, intergovernmental organizations, and nonState actors negotiate responses to health challenges’ (Smith and Irwin 2016, 7) (in which improved health is the policy goal) but also encompasses ‘health concepts or mechanisms in policy-shaping and negotiation strategies to achieve other political, economic, and social objectives’ (in which health is a means to other foreign policy objectives) (Smith and Irwin 2016, 7). Historically the focus of negotiations among nations, including international agreements on health, has been on security and trade. In recent decades, however, such negotiations have extended to human rights, conflict and fragile states, the environment, and health. At the same time, there has been an expansion and application of more global legal instruments to address global health problems (Kickbusch et al. 2012). Some of these international instruments have a long history and were developed over the past 160 years with the aim of controlling the spread of infectious diseases and addressing occupational safety and health, attesting to the importance of health diplomacy in foreign policy well before the GHD came into use (Novotny and Kevany 2013). Health issues have long been negotiated under the auspices of the World Health Organization (WHO), including the IHRs and the FCTC; but more recently have expanded to a number of multilateral venues, including various United Nations (UN) meetings and other fora that traditionally did not have a health focus. Such fora include the World Trade Organization (WTO) committee meetings and dispute panels (its negotiating rounds are presently stalled), the G7/81 and G20 summit meetings, and large non-governmental organizations (NGOs) like the Global Fund, which describes itself as a ‘21st-century partnership organization’ that functions as a ‘financing institution’ for three diseases: AIDS, tuberculosis, and malaria.2 Negotiations on health in the twenty-first century involve a broad range of actors, many of whom are not health specialists (e.g., from trade and foreign policy), and include academics, members of civil society, members of industry, NGOs, the public, and state and interstate organizations (Drager and Fidler 2007; McInnes and Lee 2012; Youde 2012). The breadth and diversity of actors creates challenges in terms of technical language, ideas and interests, and patterns of thinking (Ruger 2011), leading to difficulty in developing broadly supported norms, guidelines, rules, and regulations (Buse, Hein, and Drager 2009; Gostin and Taylor 2008; Novotny and Kevany 2013). These challenges help to explain why many early global health negotiations lacked transparency and normative clarity, undermining their effectiveness (Dodgson, Lee, and Drager 2002; Ruger 2011).

The Link between Health and Foreign Policy The link between health and foreign policy has grown stronger over the past two decades, to the point that global health issues have become normalized in foreign policy,

106   Akram Khazatzadeh-Mahani et al. High politics/hard power

National security Economic interests Development Human dignity Low politics/soft power

Figure 6.1  Foreign policy functions. Adapted from Fidler (2005).

partly because of the massive increase in health funding linked to the Millennium Development Goals (MDGs) (Feldbaum, Lee, and Michaud 2010; Feldbaum and Michaud 2010). Grasping such change, Fidler has developed a conceptual framework, see Figure 6.1, to show how the relationship of health with the basic functions of foreign policy has changed over time, outlining a hierarchy of foreign policy functions, from human dignity and development to economic and national security, and linking each function to health (Fidler 2005a; Thieren 2007). Categorizing foreign policy objectives as ‘high politics’ and ‘low politics’, a long-standing distinction in the field of international relations (Morgenthau 1962), the framework shows that health historically has been categorized as ‘low politics’, dealing with scientific, non-political, and humanitarian activities; here international health activities are considered ‘mere humanitarianism’. It was only after World War II, through the Constitution of WHO in 1946 and the International Covenant on Economic, Social, and Cultural Rights in 1966, which linked health to human rights, that the relationship between health and foreign policy deepened as human rights became an issue in Cold War diplomacy (Fidler 2005a). The end of the Cold War led to the securitization of health as the perception of security threats changed, which meant that ill health was now seen as a potential destabilizing force in the international system, especially as HIV/AIDS spread rapidly in developing countries. However, there has been limited empirical examination of the interactions between health and foreign policy (Feldbaum, Lee, and Michaud 2010; Kickbusch 2011), and there has been difficulty in distinguishing between means and goals: Is health a conduit for other (non-health) foreign policy objectives, or is foreign policy a means to directly improve health outcomes (Kickbusch 2011)? Lee and Smith (2011) elaborate on these differences; in the first instance, health is a means to achieve other foreign policy goals, such as increasing health aid to reduce the risk of conflict in strategically important countries or regions. In the second instance, other foreign policy goals are used to enhance health, such as adapting trade policy to positively discriminate in favor of healthy foods (Labonté 2014; Lee and Smith 2011). In a similar vein, Kickbusch (2011) outlines four possible interactions between foreign policy and health: foreign policy

Global Health Diplomacy   107 endangering health, health serving as a foreign policy tool, using foreign policy to promote health goals, and health serving as an integral part of foreign policy. Each of these is discussed in more detail below.

Foreign Policy Endangering Health Foreign policy has the potential to jeopardize health through diplomatic failure, such as when trade negotiations overshadow health concerns. Numerous health concerns have been raised over a recent string of regional trade and investment agreements, such as the now largely defunct Trans-Pacific-Partnership (TPP)3 agreement, which have the potential to make drugs less affordable for millions of (especially vulnerable) people through impacts on intellectual property and patent laws that prioritize commercial interests over health (Labonté, Schram, and Ruckert 2017). Similar concerns have been raised about the health implications of TTIP (the Trans-Atlantic Trade and Investment Partnership) and CETA (the Comprehensive Economic and Trade Agreement between Canada and the EU). Under WHO auspices, public health experts and diplomats have been working together to resolve issues of public health and intellectual property (e.g., WHA 61.21) (Chan, Støre, and Kouchner 2008). Such concerns eventually led a recent UN High-Level Panel on Access to Medicines to call for the development and production of health technologies and drugs in a way that better balances trade and industry interests with human rights and public health concerns (United Nations High Level Panel on Access to Medicines 2015). This does not mean that future trade and investment agreements, especially bilateral deals under the Trump administration in the United States, will follow such recommendations; rather, early indications suggest that the United States will push for even more generous protections for intellectual property rights (held predominantly by American-based transnational corporations) in the new bilateral trade and investment agreements, or the renegotiated multilateral trade deals such as the North American Free Trade Agreement (NAFTA), that it wants to pursue.

Health Serving as a Foreign Policy Tool Although public health advocates disagree with health being misappropriated for other purposes, in a highly interdependent world, few global health programs function with a purely humanitarian motive (Brainard 2007; Kickbusch 2011; Ooms et al. 2011). Ooms and colleagues (2011) point out that the ‘health of all people has not become an end of foreign policy in itself ’; using development assistance as an example, they argue that aid (including for health) is often provided by richer countries to advance their own strategic interests, security goals, and values rather than to promote better health outcomes in the global South as an end in itself (Brainard 2007; Fidler 2005b; Ooms et al. 2011). There are valid arguments that the dominant model of development assistance and donor-recipient

108   Akram Khazatzadeh-Mahani et al. relationships reflect the way high-income countries (HICs) try to impose their own agendas, values, worldviews, and predefined objectives on recipient nations (Buss and Ferreira 2010). A concrete example of this is the gross mismatch between global health needs, as measured in global disease burdens, and donor priorities expressed in development assistance for health flows. Since the 1990s the global burden of disease in  developing countries has shifted substantially, away from infectious diseases to non-communicable diseases (NCDs), yet most development assistance remains focused on infectious diseases, arguably as a strategy to contain such diseases at the source before they spread to HICs. Governments also increasingly use health programs to strengthen their relations with other countries, to help build alliances, and to increase their political reputation. While such forms of ‘medical diplomacy’ have a long history, they have recently accelerated with China’s incursions into Africa and Cuba’s international medical assistance programs (Thompson 2005). China’s foreign policy interests and political cooperation with Africa include mostly energy and food assistance, as well as infrastructure projects and medical collaboration, while Cuba has sent more than 100,000 medical personnel to over one hundred countries since the 1960s. In this process, Cuban medical teams have played crucial roles in many of the world’s health disasters, including combatting the 2014 Ebola outbreak in West Africa (Kendall 2015). More recently, under the ‘Oil for Doctors Program’, Cuba has ensured access to Venezuelan oil at subsidized cost in return for providing Venezuela with 30,000 doctors and training for 40,000 Venezuelan medical personnel annually. In a similar vein, the United States has also used medical diplomacy in its war efforts, through the US President’s Emergency Plan for AIDS Relief (PEPFAR), which was started in 2003 under George W. Bush. Introduced at the time of the internationally criticized Iraq war, its aim was not solely humanitarian, but served to improve recipient countries’ perceptions of the United States. It proved to be a successful program in health terms, leading to large reductions in infection rates and mortality (Bendavid 2016), as well as adding a humanitarian legacy to the Bush presidency (Kickbusch 2011). Similarly, Brazil, despite its recent economic turmoil, is considered a rising global power and has used its international health programs—including making available low-cost antiretroviral drugs and being a strong voice globally on improving access to medicines—as foreign policy instruments to reinforce its developing international status (Wogart et al. 2008). For example, it has successfully leveraged its program to fight HIV/AIDS into an expanded South-South cooperation effort to serve its wider foreign policy goals of reforming the UN Security Council and the international monetary system (Gómez 2009). Finally, the then prime minister of Canada used the 2011 G8 summit in his country to launch a widely recognized global health initiative, the G8 Muskoka Initiative on Maternal, Newborn and Child Health, as a way to garner international recognition and to position Canada as a major player in the multilateral health arena (Hoffman 2010; Kirton and Guebert 2009; Proulx et al. 2016).

Global Health Diplomacy   109

Using Foreign Policy to Promote Health Goals Recognizing the growing impact of foreign policy decisions on health, the foreign ministers of seven countries gathered in Oslo in 2007 and pledged to make ‘impact on health’ a key concern in foreign policy and development strategies (Amorim et al 2007). They issued the Oslo Declaration, in which global health is identified as ‘a pressing foreign policy issue of our time’ (Amorim et al. 2007; Labonté & Gagnon 2010). The declaration clearly considers health objectives ‘as a point of departure’ for foreign policy (Novotny and Kevany 2013). Some countries, notably Switzerland and the United Kingdom, have published foreign policy statements that lay out how foreign policy can serve to promote global health goals, the implication being that foreign policy should pursue health as an end in itself (Fidler 2009). It remains moot whether health has been in the past, or ever will be, a singular goal of foreign policy, although many developed countries have realized that assisting developing countries to improve their public health capacity can bring about economic, security, and humanitarian benefits (Frist 2015). Global development assistance for health exploded from around US$ 2 billion in 2000 to a peak of more than US$ 35 billion by 2015, after which it receded slightly (Dieleman et al. 2016); however, such health investments are not solely driven by the desire to improve health outcomes in health aid recipient countries, as there is growing understanding that poor recipient countries’ health can affect that of rich donor countries (Ooms et al. 2011). McInnes and Lee (2006, 2012) similarly argue that in pursuing global health initiatives, the interests of HICs are prominent in their focus on health risks in the developing world that might have an impact on their own populations.

Health Serving as an Integral Part of Foreign Policy The developments previously discussed illustrate an important shift in the relationship between health and foreign policy, in that health increasingly constitutes an essential component of foreign policy in many countries, and as a growing number of diplomats and elected officials have started to realize that health warrants a prominent place on the global agenda (Frist 2015). Three health-informed foreign policy agendas stand out: aid, trade, and national security (Feldbaum, Lee, and Michaud 2010; Fidler 2006). In some countries (e.g., Canada), health considerations have become a driving force of development policy and programming. The amount of aid and development assistance for health to low-income countries (LICs) has major implications for these countries’ population health. While several pressing global health challenges remain under-resourced (Feldbaum, Lee and Michaud 2010; Ooms et al. 2011), even when health development assistance is more donor than needs driven, health benefits can be realized. For example, US health aid to Egypt throughout the 1990s resulted in that country’s dramatic decline in child mortality by 2000 (Feldbaum, Lee, and Michaud 2010). The health implications of trade policies are now also widely acknowledged, and the literature on the health

110   Akram Khazatzadeh-Mahani et al. impacts of trade is substantial, if also contentious (e.g., Blouin, Drager, and Smith 2005; Friel et al. 2013; Owen and Wu 2007). In particular, unfair terms of trade and the inequitable impacts of agreements can widen health inequalities within and across states. An acknowledged friction between trade and investment agreement rules and health, as documented by UN human rights special rapporteurs and UN General Assembly resolutions (UN 2016), suggests the need for greater engagement regarding health in the trade policy process, where economic considerations presently predominate, to minimize ex post policy incoherence (Ruckert et al. 2017). The final element suggesting that health is becoming an integral part of the foreign policy agenda of some countries is its link to security. Transborder health risks have long been viewed as potential threats to national security, but attention to such risks has increased since the end of the Cold War (Feldbaum 2009). Arguments linking health and national security have become more frequent with concern over the proliferation of biological weapons and the potential for bioterrorism (Fidler 2003). The passage of UN Security Council Resolution 1308 in 2000 on HIV and peacekeeping in conflict situations led to the official recognition of global health as a national and international security issue. As a consequence, greater political attention and funding have been devoted to global health issues, such as the establishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria and the US$15 billion PEPFAR, mentioned previously (Feldbaum et al. 2006).

Global Health Diplomacy as a Soft Power Tool In achieving foreign policy goals, diplomatic efforts surrounding health are often understood in terms of the exercise of ‘soft power’, a term first used by the US academic Joseph S. Nye in the early 1990s to describe a country’s ability to persuade and attract others to do what it wants without resorting to coercion. Nye defines power as ‘the ability to influence the behavior of others to get the outcomes one wants’ (Nye 2004, 2) and distinguishes between ‘hard’ and ‘soft’ power. For Nye, hard power rests on threats (‘sticks’) or inducements (‘carrots’), while ‘soft power’ or ‘the second face of power’ seeks to obtain the outcomes one wants indirectly and without tangible trade-offs or resorting to economic threats and sanctions. In other words, soft power co-opts others rather than coercing them into action and ‘rests on [one’s] ability to shape [their] preferences’ (Nye 2004, 5). In contrast to hard power’s deployment of military power and economic resources, soft power is exercised through the diffusion of values, institutions, culture, and attraction. In world politics, a country may reach the outcomes it wants because other countries admire its values, aspire to its level of prosperity, and emulate its example. Global health diplomacy is largely based on the exercise of soft power (Lee and Smith 2011), and some have suggested that the growing focus on health in global political

Global Health Diplomacy   111 negotiations is a result of the growing importance of soft power in foreign policy since the end of the Cold War (Lee and Smith 2011; McInnes and Lee 2012). In global health diplomacy, Brazil is often cited as a prominent example, mainly because of its effective use of soft power to influence global politics through ideas, knowledge, and values (Gagnon 2012; Lee and Gomez 2011; Russo and Shankland 2014). Brazil supports a rights-based approach to health and civil society engagement in policymaking and has historically focused on upstream determinants of health and policy coherence across sectors (Gagnon 2012). Brazil was the first developing country to link trade and public health by successfully confronting and renegotiating the barriers to medicine access in the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS), which resulted in the country offering free antiretroviral (ARV) treatment to HIV/AIDS patients, leading in turn to a sizable decline in AIDS-related morbidity and mortality. This success story became a prime example of how to expand global support for HIV/AIDS treatment in other countries (e.g., Thailand, South Africa, India) (Nunn et al. 2009; Smith et al. 2010). Brazil’s use of soft power also enabled the country to play the lead role in the negotiations on the FCTC. Two skilled and experienced Brazilian diplomats played leadership roles in the negotiations and facilitated the successful conclusion of FCTC negotiations by building broad-based coalitions. (Lee and Gomez 2011). Finally, Brazil has disputed the traditional dominant model of aid and development assistance and donor-recipient relations by promoting ‘South–South’ or ‘horizontal co-operation’, based on mutual learning and exchange between countries. In this demand-driven model, health aid is requested by recipient countries instead of there being an external health aid package (Almeida et al 2010; Russo and Shankland 2014).

Instruments of Global Health Diplomacy Much of the extant literature on GHD highlights the central role played by WHO through its executive board, the World Health Assembly, and side meetings and special working groups, which provide the main platforms for GHD negotiations (Solomon 2013). The WHO Constitution offers authority and normative capacity to the World Health Assembly (the decision-making body of WHO, consisting of its member states) to adopt and approve normative and legally binding instruments (see box 6.1). As a normative entity, WHO sets global standards and norms (e.g., international agreements, regulations, conventions, and recommendations), acts as a powerful voice in debates about health in development, and leads and coordinates global health research (Yach 2016); however, it has seldom exercised its normative power through legally binding instruments (Gostin and Sridhar 2014). Nominally the world’s paramount health or­gan­iz­ a­tion, WHO presently faces multiple legitimacy challenges, some related to its

112   Akram Khazatzadeh-Mahani et al.

Box 6.1  The WHO’s Diplomatic Instruments The three principle GHD-relevant instruments wielded by the WHO are recommendations/­ resolutions (considered ‘soft’ instruments as they do not bind Member States in a strict international legal sense); international agreements and conventions (legally-binding instruments which are considered ‘hard law’); and regulations (legally binding ‘hard’ obligations). Examples of the first instrument include: the WHO Global Code of Practice on the International Recruitment of Health Personnel (WHA 63.16) and the Global Strategy to Reduce the Harmful use of Alcohol (WHA 63.13); of the second instrument, the Framework Convention on Tobacco Control; and of the third instrument, International Health Regulations (IHR). Even with ‘hard law’ conventions or regulations, the WHO ­cannot levy penalties against states parties or member states who renege on them, and must rely upon persuasion.

or­gan­i­za­tional structure (Gostin and Friedman 2014); others to its mandate (operational or normative or both) (Mackey 2016; Yach 2016); and still others to its inadequate funding, its reliance on external donors, the increased involvement of the World Bank in health development, and the rise of corporate health philanthropies, notably the Bill and Melinda Gates Foundation (Clift 2016). Although some urge that WHO be given additional normative power, including soft and hard law instruments, as well as a reinvention of its structure and mandates (Gostin 2015; Lee and Pang 2014; Mackey 2016; Ooms et al. 2014), it remains an open question whether WHO should be more engaged with its normative role (e.g., rule setting), its operational role, or some combination of both, given that there are other global agencies, such as those within the UN and scientific communities, that can take on some of WHO’s responsibilities.

How and Why Do Health Issues Reach the Foreign Policy Agenda? While the processes by which GHD occurs have been well described in the literature, there is no consensus on what is driving the proliferation of health diplomacy in various global fora or on how and why health issues are increasingly integrated into foreign policy negotiations (Ruckert et al. 2016). One of the few empirical studies in GHD that addresses these questions is that of Gagnon and Labonté (2013), which explored the UK global health strategy (2008–2013) using three theoretical frames: Walt and Gilson’s policy analysis triangle, Fidler’s conceptualization of health and foreign policy drawing on realist theory of international relations, and Kingdon’s multiple streams framework (Kingdon 1984). Invoking realist theory, Gagnon and Labonté argue that national and international security and economic interests were the main driving forces behind the United Kingdom’s decision to focus on global health. But additional drivers to embark on global heath include the desire to improve the United Kingdom’s international

Global Health Diplomacy   113 reputation, as well as an organized policy community and a dedicated policy entrepreneur who had expertise in both health and international relations. Building on the realist sentiment, Bergh and Gill (2013), as well as Rushton (2011), further suggest that due to the multiplying number of actors involved in foreign policymaking and agenda setting, as well the emergent number of nontraditional security challenges, global health concerns have been elevated to the status of a national (or international) security concern. The securitization of health issues, as well as the strategic use of security language when discussing health, can legitimize and incentivize additional funds and resources to address health threats that may not have been otherwise expended, but with the risk of altering health development agendas and militarizing health aid. This interest- and security-centered understanding of GHD, however, has also been criticized as being too narrow from both constructivist and cosmopolitan theoretical perspectives. Through the constructivist lens, the current global context is characterized by various state and nonstate actors and their interests, as well as constantly interacting political, social, and economic factors that shape global health outcomes and to which actors react in different ways. Constructivists argue that actors’ interests expressed in the international domain are not materially given but are based on their ideational understanding of material structures (Davies 2010). The very process of interactions through diplomatic channels can affect how states and nonstate actors formulate their political preferences and articulate interests. Thus health diplomatic processes become more than mechanical conduits for articulating and defending predetermined (security or economic) interests; rather, they become means by which states and nonstate actors intersubjectively construct and express their ideas, interests, and identities (Fidler 2011). In addition, constructivists also emphasize the important role of nonstate actors in GHD, which is largely neglected by realist theory. Nonstate actors utilize expert and advocacy networks based on shared values, norms, and understandings to influence the agenda-setting process in GHD, as well as ensuring that they frame global health concerns in an assortment of ways in hopes of invoking non-interest-based state responses (Keck and Sikkink 2014). In this ideas-driven understanding of GHD, the ideas and discourse surrounding global health diplomacy are not necessarily generated by the most powerful states (as assumed by realist theory), but rather by close networks of actors through the sharing of ideas and values, including various nonstate actors. This does not preclude the importance of a ‘focusing event’ as described in Kingdon’s work (1995), such as the role of SARS in sparking an overhaul of the IHRs and initiating ongoing international discussions of health security. But constructivists are more interested in how such discussions shape norms and decisions than in a linear explication of how international policy processes proceed. The cosmopolitanist argument for the integration of health into foreign policy suggests that existing health disparities between nations, such as differences in life expectancy and the under-five mortality rate, have become both readily and almost instantly observable as a result of globalization’s erosion of border barriers, the diffusion of digital technologies, and the information revolution. These increasingly apparent, and in some cases growing, health disparities have invoked a global response and

114   Akram Khazatzadeh-Mahani et al. contributed to the growing notion of a single global community (Lencucha 2013). Figuié (2013) draws attention to the emergence of the ‘One World One Health’ paradigm, pursued by international organizations, which calls upon actors to ‘progressively construct shared perceptions of health risks and to build coordinated response to global health issues’, emphasizing the cosmopolitan nature of an emerging community of responsibility that could transcend borders and conflicts in the face of global health risks (230–231). In other words, what is driving the integration of health into foreign policy is not security interests (at least not singularly) but a shared morality risk and a duty by developed countries to contribute to lasting health improvements among vulnerable populations (Lencucha 2013).

Evaluating GHD Global health diplomacy covers a wide range of processes, from developing binding and non-binding GHD instruments to finalizing agreements between bilateral or multilateral aid donors and recipient countries. There remains a lack of reliable evidence about the effectiveness of such efforts (Smith and Irwin 2016), with calls for more empirical evidence on the diplomatic and health effects of soft power initiatives (Kickbusch 2011). Sporadic evidence reveals the success of GHD-led programs like PEPFAR in terms of their impact on mortality (Bendavid 2016); for example, Bendavid and Bhattacharya (2009) reported a 10.5 percent drop in HIV-related mortality in twelve countries receiving aid from PEPFAR. As another example, Kevany and colleagues (2015) report on the success of the Global Fund in advancing altruistic and diplomatic goals simultaneously. They argue that global health programs have contributed considerably to non-health goals such as the pursuit of national integration/internal unity, development, and regional international relations in South Pacific countries, while having a significant impact on the control of communicable diseases and health system strengthening (Kevany et al. 2015). Recently conducted health impact assessment (HIA) studies of regional trade agreements (e.g., the TPP) also constitute part of this evidence (e.g., Hirono et al. 2016; Ruckert et al. 2017). Yet critical questions that remain largely unanswered, as initially outlined by Lee and Smith (2011) and reaffirmed by Smith and Irwin (2016), include the following: • How can the quality of GHD initiatives be measured in terms of their effectiveness, accountability, transparency, and representativeness? • How should GHD success or failure be assessed? • What sort of qualitative and quantitative methods are required for GHD evaluation? • How are GHD outcomes implemented at the national level? • How effective are institutions/agencies in formally conducting GHD (e.g., WHO) functions? • Which venues are most effective for conducting GHD?

Global Health Diplomacy   115 The two main strands of existing GHD evaluations are those directed at global health programs (e.g., global health funding) and those examining the success of various GHD instruments (e.g., WHO regulations, treaties, conventions). Traditional evaluation measures of global health programs typically focus on short-term, performance-based outputs like financial disbursements (e.g., cost-effectiveness analysis) and health outcomes, and they fail to measure the implicit, indirect, and long-term outputs, outcomes, and impacts of such programs. While these traditional measures can help advance program outcomes in resource-constrained settings, they have the potential to undermine general health budgeting and consequently the overall health gains by their narrow focus on specific program outcomes and exclusion of broader political and diplomatic factors. Recipients, donors, and governments are now also seeking more inclusive measures that reflect actual health gains. In an era of smart power, which persists despite the rise of ‘alt-facts’ and ‘fake news’ in the Trump administration’s ideological undermining of any concept of truth or reality, we need ‘evaluation studies on the outcomes of GHD and related assistance programs from the economic, political, international relations, diplomatic, and human rights standpoints’ (Novotny and Kevany 2013, 309)—that is, a much broader set of impacts to study. The success of GHD instruments has traditionally been measured by the production of an instrument (e.g., resolutions, conventions, regulations) and not by their health impacts, as it is argued that a GDH instrument can only impact health if it has political purchase at the national country level. This presents two challenges: how (with what means/measures) and when (at the time of endorsement or implementation at the country level) to measure success at this national level (Smith and Irwin 2016). In a recent case study, the interaction between GHD instruments and national-level implementation was explored with a focus on India and WHO’s Set of Recommendations on the Marketing of Food and Non-alcoholic Beverages to Children, endorsed in 2010 (Smith and Irwin 2016). The study found that India neither took immediate steps to implement the WHO recommendations nor reduced food marketing to children. In another example, Smith and Irwin (2016) refer to the WHO Global Strategy for Diet, Physical Activity and Health, endorsed in 2004, which took six years to be implemented in India. Neither case, the authors argue, represents GHD failure, but both reflect the reality that adoption of global norms at the country level takes time and that ‘implementation of global health diplomacy outcomes must be conducted within national contexts and limitations’ (Smith and Irwin 2016, 4).

Conclusion: The Way Forward in GHD This chapter outlines some of the key aspects and discussions of how health has increasingly become a political concern in global fora, leading to diplomatic efforts to solve global health problems. It demonstrates the political nature of GHD processes, which can be simultaneously driven by security and economic interests, as well as by broader norms and values. While GHD negotiation processes have been well-described and

116   Akram Khazatzadeh-Mahani et al. studied in the literature, more emphasis needs to be placed on evaluating the health impacts of GHD and providing better theoretically grounded explanations for its emergence. This could be achieved through a more meaningful engagement with the field of political science in general and with international relations theory in particular. Drawing on analytical tools from the field of political science will serve to refocus attention away from biomedical interventions as the panacea for global health problems and reinforce the notion that global health is ‘anything but simply a technical pursuit’ (Davies et al. 2014, 829), in which GHD plays a central role in engendering the political will to address global health concerns. Of special importance will be how power, in particular corporate and state power, can shape GHD outcomes, and how to measure and theorize the impacts of power on GHD results (Ruckert et al. 2016).

Notes 1. Health issues became prominent in G7 meetings in the late 1990s. When Russia joined the group in 1997 it became the G8. It reverted to G7 when Russia was ‘suspended’ in 2014 over its annexation of Crimea. 2. The Global Fund is formally known as the Global Fund to Fight Aids, Tuberculosis and Malaria (GFATM) but now goes by the simpler, shortened label. It formed in 2000/2001, a result of negotiations between WHO and G8 countries, and began operations in 2002. 3. At the time of writing (May 2017) the TPP is more properly considered a zombie treaty rather than a defunct one. While no longer actionable as negotiated, with the withdrawal of the United States, there have been several initiatives to resurrect it with a different set of countries or to import its provisions intact into new bilateral or smaller regional agreements.

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chapter 7

Secu r it y a n d H e a lth Simon Rushton

over twenty-one million passengers pass through Washington, D.C.’s, Dulles airport every year (MWAA 2016). Most of those journeys are uneventful. That could not be said of the journey of Thomas Eric Duncan, who arrived at Dulles on September 20, 2014, on flight UA951 from Brussels, Belgium. After clearing immigration, Duncan boarded a flight to Dallas/Fort Worth. In Dallas he fell ill—and was eventually diagnosed with Ebola virus disease (EVD). On October 2 the New York Times reported that Duncan had lied at Monrovia airport before boarding his Brussels-bound flight, denying having had any contact with the disease despite having helped take an Ebola patient (who died of the illness on September 16) to hospital. Binyah Kessselly, chairman of the Liberian Airport Authority, was quoted as having said that Duncan would be prosecuted upon his return to Liberia (Onishi and Santora 2014). Duncan never did return; he died in the Texas Health Presbyterian Hospital on October 8. Two nurses who had treated him also contracted the disease; both recovered. Only a few days before Duncan landed at Dulles, on September 16, President Barack Obama had used a speech at the Centers for Disease Control and Prevention (CDC) in Atlanta as an opportunity to address public fears about the threat posed to the population of the United States by the Ebola outbreak then under way in West Africa. Obama said: First and foremost, I want the American people to know that our experts, here at the CDC and across our government, agree that the chances of an Ebola outbreak here in the United States are extremely low. We’ve been taking the necessary precautions, including working with countries in West Africa to increase screening at airports so that someone with the virus doesn’t get on a plane for the United States. In the unlikely event that someone with Ebola does reach our shores, we’ve taken new measures so that we’re prepared here at home. We’re working to help flight crews identify people who are sick, and more labs across our country now have the capacity to quickly test for the virus. We’re working with hospitals to make sure that they are

124   Simon Rushton prepared, and to ensure that our doctors, our nurses and our medical staff are trained, are ready, and are able to deal with a possible case safely.  (Obama 2014)

Evidence that subsequently emerged, including in the congressional hearings ­following Duncan’s death, pointed to failures related to each of those promises. Duncan had been able to board a flight; he was not successfully diagnosed on his first visit to hospital; and infection control procedures within the hospital had failed, leading to the two nurses contracting the disease. Representative Tim Murphy, chairing the congressional hearing, said that ‘[t]he trust and credibility of the administration and government are waning as the American public loses confidence each day, with demonstrated failures of the current strategy’ (cited in Morgan 2014). The Ebola virus Thomas Duncan was carrying inside his body was widely interpreted as not only a medical or public health problem, but also a national security threat to the United States and its population—and a potential global security threat. The Duncan case provided a classic illustration of a number of debates that have surrounded the concept of ‘health security’ at both the national and global levels (Aldis 2008). First, to what extent was it possible for the United States to prevent importation of the virus in a highly globalised world? Second, could the threat Ebola posed to the United States best be addressed at the US border, or should greater effort be put into containing the ­outbreak in West Africa? Third, were the domestic preparedness measures that Obama had announced on September 16 adequate, or should more effort and resources have been put into readiness for a potential US outbreak? Fourth, how should infected individuals (and those thought to be at risk of infection) be dealt with? To what extent should their civil liberties be restricted? Strikingly, all four of these questions could, with only minor amendment, be asked about many other contemporary security challenges, not least the threat of international terrorism. This goes to show how deeply entrenched the securitisation of disease is in American political discourse and that of many other countries of the global North. ‘Security’, however, remains a contested concept. As is evident in other chapters in this volume (see, e.g., chapters by Enemark and Nunes), a wide range of different understandings of ‘security’ can be applied to health and disease, from relatively traditional understandings of ‘national security’, in which states seek to protect their territories, populations, and economies from outbreaks of deadly diseases, to more human-centred or critical accounts that focus on the threats posed to individuals and communities. Each of these approaches to security leads to different answers to the questions of who or what is being secured, from what, and how that security should be achieved in practise (Aldis 2008). This chapter examines and critiques the ways in which diseases have come to be seen as national and international security threats. It begins with a brief examination of the long history of disease as a threat to societies, then turns to the deepening linkages between disease and national security in the post–Cold War era. The chapter then examines four health threats that have found their way firmly onto Western security

Security and Health   125 agendas since the 1990s: emerging infectious diseases, HIV/AIDS, bioterrorism, and drug-resistant infections. It focuses in particular on the ways in which the public health and security communities combined to construct these particular problems as security threats. In the third section the chapter examines some of the apparent benefits of framing diseases as security threats. The fourth and final section examines some of the critiques that have been made of the securitisation of health, noting that these point to the need for policymakers to grapple with deeply political trade-offs regarding how much ‘security’ we want from disease and what we are prepared to sacrifice in order to achieve it.

Disease and Insecurity: A Brief History Diseases have always crossed political boundaries and posed problems for the functioning of societies. In examining the history of epidemics since antiquity, Andrew PriceSmith (2009, ch. 2) shows that diseases have challenged societies in a variety of ways that go far beyond the effects of morbidity and mortality resulting directly from the disease itself. The impacts of disease have included inducing political and social instability (in extreme cases even contributing to the collapse of entire civilisations, as occurred when Amerindian societies were devastated by smallpox), causing migration as people attempt to ‘get out of harm’s way’, undermining economies, and playing a part in determining the course of armed conflicts. Globalisation, however, is generally understood to have fundamentally changed the nature of the cross-border disease threat as a result of the more extensive, and more rapid, international movement of people, animals, food, and other goods. It has become a truism of global health that ‘an outbreak or epidemic in any one part of the world is only a few hours away from becoming an imminent threat somewhere else’ (WHO 2007, x). But whilst globalisation-related changes have no doubt sped up the geographical movement of pathogens, such spread was always a reality of life on earth. As a result, fear of the importation of pathogens from a dangerous outside world has been a topic of political discussion and action for centuries. The origins of the modern discipline of global public health can be traced back to colonial-era ‘tropical medicine’ (Aginam 2003). Whilst tropical medicine was, on the face of it at least, concerned with dividing the world climatically—between the ‘tropics’ and the temperate climates of Western Europe and North America—it frequently slipped into ideas that seem jarring to modern ears, including tropes about primitive and unhygienic lifestyles, disease-causing cultural practises in the (colonised) tropics, and the superiority of imperial medical knowledge and technologies. As Alison Bashford (2004), amongst others, has noted, tropical medicine became not only about health narrowly defined, but part of the wider ‘systems and cultures of race management’ designed to segregate the safe spaces of the coloniser from the dangerous colonised through cordons sanitaires and other public-health-framed policy interventions.

126   Simon Rushton Gregory Bankoff finds in contemporary discussions of Western vulnerability to disease a continuation of a very similar discourse, which denigrates large regions of the world as dangerous—disease-ridden, poverty-stricken and disaster-prone; one that depicts the inhabitants of these regions as inferior— untutored, incapable, victims; and that it reposes in Western medicine, investment and preventive systems the expertise required to remedy these ills. (Bankoff 2001, 29)

The earliest international efforts by governments to develop transnational cooperative mechanisms to mitigate the risk posed by the cross-border spread of pathogens fit neatly into these colonial logics, with their focus on protecting Europe from less ‘civilised’ (and more disease-ridden) parts of the world. Such efforts are most commonly traced back to the International Sanitary Conferences of the mid-nineteenth century, which brought together European states concerned with harmonising quarantine regulations to control cholera, plague, and yellow fever. The gradual institutionalisation of these international arrangements (Hoffman 2010) led ultimately to the adoption of the International Sanitary Regulations (ISRs—later renamed the International Health Regulations (IHRs)) by the newly established World Health Organization (WHO) in 1951 (WHA 1952). In 2005 WHO member states adopted the most recent revised set of IHRs (which remain in force at the time of writing), widely seen (not least by WHO) as being the centrepiece of global arrangements to provide for ‘global health security’. Whilst disease is often spoken of as a ‘new security challenge’, only emerging on mainstream national security agendas in the post–Cold War era, the idea that disease poses a security threat is not new. Szreter (2003) has argued that it is the separation of health and security rather than their coming together that is relatively recent. Yet it is clear that something changed in the 1990s and early 2000s. National security and public health policy communities increasingly found themselves discussing the same issues, and doing so in similar terms. The extent to which (particularly Western) security policy communities have added health issues—especially infectious diseases—to the range of threats that they routinely concern themselves with is striking. Health threats have become a fixture on national security agendas in much of the developed world, changing the way in which security is practised and leading to what Stefan Elbe (2010) has termed a ‘medicalisation of security’. The ending of the Cold War, which had dominated national security policymaking for decades, is generally credited with having opened up space on the agenda for issues such as infectious disease (e.g., Buzan 1997). Yet it is also the case that the concerted efforts of some in the public health community to frame certain health issues in security terms played an important part in constructing disease as a national security threat. The next section examines the ways in which certain health-related issues have been ‘securitised’—that is to say, have come to be commonly defined as security threats. In particular it focuses on the four health issues that have become most firmly embedded on Western national security agendas, showing how, from the 1990s onwards, the health and security

Security and Health   127 policy communities combined to convince political leaders that these challenges should be prioritised as national (and indeed international) security threats.

The Construction of Health Security Threats This section examines four of the disease-related issues that have become most prominent on mainstream national security agendas in the post–Cold War era, examining how they got there and who advocated for securitisation. Proceeding chronologically, the discussion begins with emerging infectious diseases (EIDs), which began to be discussed frequently in national security terms in the 1990s, before moving on to HIV/AIDS (late 1990s/early 2000s), bioterrorism (early 2000s), and antimicrobial resistance (AMR) (2010s). In each of these cases, it is argued that key figures from public health, alongside national security actors, played important roles in establishing the idea that the issues in question should be thought of as security threats.

Emerging Infectious Diseases Emerging infectious diseases are usually defined as diseases that have ‘newly appeared in the population, or have existed but are rapidly increasing in incidence or geographic range’ (Morse 1995, 7). They can take a variety of different forms and can emerge in a variety of different ways. Zoonoses (diseases originating in animals) are one common source of EIDs. In the late 1980s and early 1990s Joshua Lederberg, a molecular biologist, and Stephen Morse, a virologist, were two of the most prominent individuals calling for greater attention to be paid to the threat of EIDs. Both were involved in a high-profile conference on EIDs held in Washington, D.C., in 1989, and both contributed to Emerging Infections: Microbial Threats to the US, a highly influential report published by the US Institute of Medicine (IoM) in 1992 (Lederberg et al. 1992). That report captured the attention of high-level security policymakers in the US government, laying the groundwork for EIDs becoming more widely interpreted as potential threats to national security in the United States, and later globally (Weir and Mykhalovskiy 2010, 32–40). In the late 1990s it was followed up by a further IoM report, America’s Vital Interest in Global Health (Institute of Medicine 1997), and the US National Intelligence Council’s National Intelligence Estimate on ‘The Global Infectious Disease Threat and Its Implications for the United States’ (NIC 2000), both of which prominently featured the claim that EIDs posed a threat to US national security. Whilst the concern about EIDs first took hold in security policy circles within the United States, gradually this discourse became more prominent internationally, not least once it reached the agenda of WHO (Weir and Mykhalovskiy 2010, 43–54).

128   Simon Rushton A few years later the SARS (severe acute respiratory syndrome) outbreak of 2002–2003 provided a dramatic example to anyone still unconvinced of the ways in which EIDs could pose a threat not only to national security, but also to global security (Davies, Kamradt-Scott, and Rushton 2015; Fidler 2003). SARS was a previously unknown disease that jumped the species barrier to infect humans in southern China at some point in late 2002. It came to worldwide attention in early 2003 when the virus was identified in Hong Kong, having been brought into the territory by a doctor visiting from mainland China. From Hong Kong, the virus rapidly spread around the world. By the time the SARS outbreak was declared over in July 2003, 8,096 people in twenty-nine countries and territories had been infected; 774 of them died (WHO 2003). As well as the loss of life, SARS also highlighted the economic impacts of outbreak emergencies. As one example of its effects, Watson (2006, 201) reported that ‘at the height of the SARS scare, the occupancy rate of Hong Kong’s major hotels fell to 5 percent, and it was rumoured that, on some nights in April 2003, two of the territory’s grandest hotels did not have a single guest’. Although post-SARS analyses (e.g., KeoghBrown and Smith 2008) suggested that the actual economic losses attributable to SARS had been much lower than some of the direst predictions at the time had forecast, the costs were nevertheless significant and were a significant factor in motivating governments around the world to take the EID threat more seriously. That situation was reinforced by a series of subsequent transnational disease emergencies, including H5N1 avian influenza virus in 2004–2005; the H1N1 (‘swine flu’) influenza pandemic in 2009; Middle East respiratory syndrome (MERS) from 2012; and most recently, the Ebola outbreak in West Africa, which began in 2014. All of those events, each originating in a different region (Asia, North America, the Middle East, and West Africa, respectively), again showed what Lederberg, Morse, and their colleagues had argued: that there was increased vulnerability to infectious diseases ‘in a world represented as increasingly interconnected economically, socially, and microbiologically’ (Weir and Mykhalovskiy 2010, 34). As well as threatening the security of individual nations, in a globalised world these diseases represented a global threat—a reality pushed strongly by WHO in its calls for strengthening the international disease surveillance and containment systems designed to ensure ‘global health security’ (WHO 2007).

HIV/AIDS Although as far back as the 1980s US intelligence agencies had begun investigating the possibility that high levels of HIV/AIDS could be a threat to the stability of states in subSaharan Africa (CIA 1987), it was around the turn of the millennium that the links between AIDS and security began to be seriously discussed at the international level (McInnes and Rushton 2010). The inclusion of AIDS on the agenda of the UN Security Council in January 2000—the first time that body had ever discussed a health issue— has been widely understood as a seminal moment not only in the securitisation of HIV/ AIDS, but also in the securitisation of health more widely. As with EIDs, advocates from

Security and Health   129 both the public health and the security policy communities argued for greater account to be taken of the security implications of AIDS. From the health side, Peter Piot, a virologist who was then head of UNAIDS (the Joint United Nations Program on HIV/AIDS), was an influential supporter of getting AIDS on the Security Council’s radar. He was (and is) explicit that this was part of a broader strategy to increase high-level political attention and commitment to tackling HIV/AIDS. Piot later wrote about the Security Council’s discussion of the subject as a ‘tipping point’ in the global response to AIDS: In the space of a year, it became an urgent, unavoidable subject for world leaders and organisations. . . . We succeeded in elevating AIDS to levels at which no health issue had ever been discussed before—to where the heavy lifting of international and national politics takes place.  (Piot 2012, 273)

To achieve this, Piot worked alongside Richard Holbrooke, the US ambassador to the United Nations. Holbrooke was crucial in convincing key colleagues in the Clinton administration—not least Vice President Al Gore—to actively support the council’s discussion of the issue, and also in persuading his fellow Security Council members first to devote time to a discussion of AIDS and second to adopt a resolution. As Holbrooke (2006) recalled, in terms strikingly similar to Piot’s: ‘We were breaking the issue out of the field of health specialists and into the international consciousness as a security issue’. Although AIDS has a high death toll and in some countries in sub-Saharan Africa is one of the largest killers, the way in which AIDS was constructed as a security threat was unlike the way EIDs was. Although there were arguments made about the economic costs of disease in both cases, AIDS was not presented as a security issue because of a threat of importation into previously unaffected countries (after all, HIV was already present in every country in the world by 2000), but rather as a contributor to more traditional security problems of conflict and state fragility. Of biggest concern was the threat that high levels of AIDS could pose to the stability of states (especially in sub-Saharan Africa); the looming threat posed by increasing infection rates in ‘next wave states’ (including emerging powers seen as critical to regional and global security, such as China and India); and the impact that the virus could have on the effectiveness of military and security forces (including UN peacekeepers), which were seen as being at particularly high risk of infection.

Bioterrorism Again linked to earlier security concerns, this time biological warfare, bioterrorism became a prominent national security concern in the late 1990s—and even more prominent from 2001 onwards. The attacks of September 11, 2001 (9/11), and the letters containing anthrax posted to media organisations and US senators in the weeks afterwards, understandably revitalised policymakers’ interest in bioterrorism as a pressing national security threat.

130   Simon Rushton By the late 1990s it had become common to talk about the ‘new’ terrorism, carried out by groups who were more likely to be religious in inspiration rather than pursuing explicitly political aims like those of the 1960s, 1970s, and 1980s (e.g., Laqueur 1999). Such groups, it was said, would be more willing to carry out mass-casualty attacks and to kill themselves in the process. They would be less amenable to negotiation with governments. Developments such as the internet and mobile communications gave them new ways to organize and prepare attacks. And the collapse of the former Soviet bloc gave them new opportunities to create weapons of mass destruction (WMD)—or even to get hold of ready-made WMD. That such groups could draw upon expertise or materials from the collapsed Soviet biological weapons programmes, or that they might develop their own ‘in-house’ capacity to create such weapons, seemed logical—almost inevitable, even—to many security policymakers. Public health officials were also alert to the threat. The CDC, for example, put significant resources into preparing for a potential bioterror attack, creating preparedness plans, stockpiling vaccines and antivirals, and running simulation exercises to test and improve the public health response (https://emergency.cdc.gov/bioterrorism/prep.asp). Public health’s centrality to any such response also offered an opportunity to make a case for greater investment in key public health infrastructure that would, it was argued, strengthen the response to both naturally occurring and malicious disease events. In the United States in particular, spending on biodefence increased markedly in the wake of the 2001 attacks, building on pre-existing claims for the value of such investments. As Senator Bill Frist said one week before 9/11: Arms control negotiators have used the term ‘dual use’ to refer to biologic production facilities that have the potential to be used by some countries to produce vaccines for children one week and then produce bacteria or viruses for biological weapons the next. But we can use the term ‘dual use’ differently: The same infrastructure investments used to prepare our public health communities, doctors and federal agencies to detect, diagnose and respond to a smallpox epidemic resulting from a biologic attack can also be used to detect and respond to outbreaks of natural occurring diseases like West Nile.  (Committee on Foreign Relations 2001, 103)

The anthrax letters aside, however (and it is important to note that Bruce Ivins, the man almost certainly responsible for those attacks, was himself an employee of the US Army’s biodefence programme), the feared bioterrorism attacks have not come to pass, at least at the time of writing. Indeed, debates continue over the extent to which terrorist groups in fact have the motivation to use biological weapons (e.g., Cronin 2003; O’Neill 2003), and if they do, whether they would be able to overcome the technical barriers to producing an effective weapon (e.g., Ben Ouargrham-Gormley 2012).

Antimicrobial Resistance Antimicrobial resistance refers to bacteria, viruses, and fungi having developed re­sist­ance to the drugs that have been developed to kill them. Resistance has been recognised as a

Security and Health   131 problem since antimicrobials were first invented, with resistance to sulphonamides being reported as early as the late 1930s (Davies and Davies 2010, 418). In more recent years, however, AMR has come to be seen as a more pressing public health problem due to a combination of increased use of drugs, especially antibiotics (in both humans and animals), leading to the more rapid and extensive emergence of resistant strains, and a shortage of new antimicrobial drugs coming onto the market. The rise of AMR has led some to fear that we will soon find ourselves living in something akin to the pre-antibiotic era, with even minor surgical procedures being highly dangerous as a result of the risk of infection by untreatable bacteria (e.g., Ventola 2015). As with EIDs and HIV/AIDS, over time drug resistance has come to be spoken of not only as a public health problem, but also as a national security threat. Once again, the push for securitisation has come from a combination of agents from the worlds of health policy and security policy. In the United Kingdom the government’s chief medical officer, Dame Sally Davies, has been a prominent advocate for AMR to be recognised as a national security threat. In 2011 Davies released a report that described antimicrobial resistance as a ‘catastrophic threat’ and argued: There is a need for politicians in the UK to prioritise antimicrobial resistance as a major area of concern, including it on the national risk register (specifically, the ‘National Security Risk Assessment’) and pushing for action internationally as well as in local healthcare services.  (Chief Medical Officer 2011, 16)

David Cameron, then the UK prime minister, commissioned economist Jim O’Neill to investigate the AMR issue. O’Neill’s report, which gained significant attention both domestically and internationally, began by arguing that AMR ‘needs to be seen as the economic and security threat that it is, and be at the forefront of the minds of heads of state, finance ministers, agriculture ministers, and of course health ministers, for years to come’ (Review on Antimicrobial Resistance 2016, 1). Barack Obama (at the time president of the United States) issued an executive order in 2014 declaring that ‘combating antibiotic-resistant bacteria is a national security priority’ (Obama 2014). At the same time, organisations such as WHO have explicitly identified AMR as a threat to global health security (WHO 2014a)—a claim that was also commonplace during the UN’s 2016 High Level Meeting on AMR (United Nations 2016). Both the threat of the importation of drug-resistant pathogens and the potential morbidity, mortality and economic impact they could cause have been at the heart of security framing. The solutions to these problems, however, are seen to lie not in border controls but rather in developing international cooperation around antimicrobial stewardship (which involves, e.g., addressing prescribing practises and the agricultural use of antibiotics) to preserve the effectiveness of existing antimicrobials and in research and development into new drugs. Both of these are policy responses that are far removed from what we might traditionally think of as ‘security practises’. As Stefan Elbe has argued, alongside the securitisation of health has been a simultaneous ‘medicalisation of security’ in which ‘our conception of insecurity in international politics is becoming partially redefined as a medical problem’ (Elbe 2010: 23) and in which our understanding

132   Simon Rushton of ‘security practises’ has expanded to incorporate responses that previously would have been thought of as the domain of health and medicine—an issue to which we return below.

The Benefits of Securitising Health Whilst the previous section focused on the roles of public health and security actors in promoting the idea that various health-related issues represent security threats, this section examines their motives in doing so. Specifically, it focuses on three purported benefits of securitising health, each of which has been widely discussed in both the academic literature and the policy discourse.

Security Threats Generate More Concerted Responses One of the common claims for disease’s status as a national security issue, particularly prominent in the EID, bioterrorism, and AIDS cases, but also present to some extent in the AMR case, is that diseases (whether naturally occurring or deliberately spread) can cause political, social, and economic disruption and therefore need to be recognised (and responded to) as security threats. Andrew Price-Smith (2009, 20–22) notes that the impacts of major outbreaks include economic impacts (e.g., through reduced productivity, disruption to foreign trade, and the destabilisation of markets); governance impacts (e.g., undermining a government’s ability to operate in the normal way, and reducing the effectiveness of the institutions charged with upholding law and order); and impacts on a state’s international relations (such as an increase in cross-border migration or the imposition of travel restrictions). It is clear that severe outbreaks of infectious disease could lead to all of these impacts, and some of the common measures (such as ‘social distancing’, which often involves the closure of schools and public transport) put in place in response to an outbreak can also have detrimental effects on society and the economy. In an attempt to mitigate such disruption, states frequently enact emergency measures during outbreaks, and even in ‘normal times’ many states have engaged in activities such as preparedness planning—in theory making populations safer than they would otherwise be when and if a health emergency occurs. Such planning has been particularly in evidence around a potential future influenza pandemic—one of the most prominent EID concerns—as well as around bioterrorism (see also the chapter on bi­o­ se­cur­ity by Enemark, in this volume). The majority of developed Western states have developed influenza pandemic preparedness plans (e.g., Council of Australian Governments Working Group on Australian Influenza Pandemic Prevention and Preparedness 2011; Homeland Security Council 2005; Public Health Agency of Canada 2006; Public Health England 2014). These types of activities have only occurred, the argument goes, because political leaders have been persuaded that their national security is at stake, causing them to address the threats with an urgency that (arguably) would not exist for ‘mere’ public health threats.

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Collaborations between Security and Public Health Actors Are Effective It may be the case that the involvement of security actors in addition to public health actors in responding to diseases does in fact make populations safer from disease. Addressing the threat posed by infectious disease calls for a variety of forms of action at both the national and international levels, many of which rest on well-established security concepts and practises. Whilst public health expertise clearly remains central, activities such as surveillance and intelligence gathering for the detection of emerging disease threats (either natural or man-made), preparedness planning, and crisis management are all core functions of security institutions. As a result, we have increasingly seen security actors fulfilling these roles in relation to infectious diseases alongside their counterparts from public health. Furthermore, as we saw in relation to bioterrorism, it can be argued that the efforts of security policymakers to put in place defences against malicious disease threats can have beneficial knock-on effects for naturally occurring outbreaks. Some, however, have doubted whether such purported ‘win-wins’ actually occur in practise. Fidler and Gostin (2007) have called the ‘synergy thesis’ into question, including by drawing attention to the tension between security’s privileging of secrecy and health researchers’ traditional principles of scientific freedom and open dissemination of findings. It has also been argued that the huge investment in biodefence research (especially post-9/11) has resulted in the prioritisation of programs focusing on a narrow range of biological agents whilst diverting attention from other naturally occurring disease threats (Scientists Working Group on Biological and Chemical Weapons 2010). Conversely, as Elbe (2010) has noted, the medicalisation of security has led to a far greater level of involvement of medical and public health professionals in formulating national security policy (Elbe 2010, 54–62). This has been important in addressing concerns that security institutions lacked the necessary expertise to deal properly with health threats, but it has also served to cement health’s status as a security issue, reducing the risk that it will drop off the agenda in future, and to foster institutionalised cooperation between security and public health agencies. The result is that security and health policy communities work together far more than previously to protect their populations from disease. Without that close collaboration, citizens would potentially be in greater danger.

Securitisation Brings Attention and Resources Perhaps the most commonly identified benefit is the idea that framing diseases as security threats can help capture high-level political attention and the deployment of resources to public health. This was certainly recognised in the statement by Peter Piot quoted above, in which he argued that getting HIV/AIDS onto the Security Council agenda elevated the issue ‘to where the heavy lifting of international and national

134   Simon Rushton politics takes place’. Indeed, this is central to securitisation theory, according to which securitisation can have the effect of lifting an issue above ‘normal politics’, making it ‘so important that it should not be exposed to the normal haggling of politics but should be dealt with decisively by top leaders prior to other issues’ (Buzan, Waever, and de Wilde 1998, 29). There is certainly some evidence that securitisation has been successful in relation to some of the health issues discussed in this chapter. David Fidler, indeed, has argued that ‘the frequency with which health concerns have cropped up in the realm of national and international security . . . suggests that the pursuit of health capabilities has become important even for the highest of high politics’ (2005, 183). Since the turn of the millennium, for example, the G8 (Group of Eight) has demonstrated a significant commitment to global health issues, leading to the creation and financing of new institutions such as the Global Fund to Fight AIDS, TB and Malaria and the launching of the Global Health Security Initiative. The US government created the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003—a programme that now claims to directly support treatment for 11.5 million people worldwide (PEPFAR 2016). WHO, in the aftermath of the SARS outbreak, led the way in successfully concluding negotiations for a revised set of IHRs (Davies, Kamradt-Scott, and Rushton 2015). AMR has appeared on the agendas of the G7 and G20. It seems certain that the perception of these particular health issues as security threats has played a part in this prioritisation.

Sacrifices for Security Despite the enthusiasm of some in the public health community for getting health issues on the security agenda, the international relations literature has generally been critical of the securitisation of health, pointing to some of the downsides inherent in ‘playing the security card’ (e.g., Elbe 2011). It has been argued, for example, that the kinds of emergency responses that securitisation promotes can undermine international cooperation, can be injurious to civil liberties and human rights, and can lead to the global health agenda becoming distorted towards prioritising the small number of diseases seen (by the West) as security threats, rather than those that cause the greatest levels of sickness and death worldwide. All of these critiques hold some truth. In practise, however, policymakers are left with the difficult task of striking an appropriate balance amongst competing policy objectives, norms, and principles. The questions they often face are not whether security from disease should or should not override their other concerns, but (1) how much security we need from disease threats, given that in a globalised world we can never be 100 percent secure, and (2) what we are prepared to sacrifice to achieve that level of security. In the final section I examine three such ‘trade-offs’ that have to be made by policymakers in responding to (and preparing for) health security threats.

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Human Rights and Civil Liberties Seeking to protect populations from disease often raises tensions around the human rights and civil liberties of individuals, especially those individuals infected with the disease in question who may on one level be seen as victims or patients, but on another as posing a threat to the wider population. Authorities have long faced this trade-off in disease emergencies, from the practise of ‘shutting up’ infected houses during the plague in seventeenth-century London (McKinlay 2009) to the enforced quarantine procedures put in place in Liberia in an attempt to control the spread of Ebola (Eba 2014). HIV/ AIDS has inspired a particularly vigorous debate over the rights of people living with HIV and AIDS, leading to particular sensitivities around securitisation in that case. In part the latter was a result of the fact that many of those communities most affected (such as men who have sex with men, sex workers, and intravenous drug users) had been victims of discrimination and denial of rights even before HIV came on the scene. Yet the approaches taken by many governments, particularly in the early years of the pandemic, included highly controversial national policy responses, such as the US quarantining of Haitian refugees at Guantanamo Bay in the early 1990s (Johnson 1994; Farmer 2003) and (some have argued) the Cuban government’s use of mandatory quarantine as part of its AIDS response (Bayer and Healton 1989; D’Adesky 2004, ch. 5; but see also Anderson 2009). When faced with perceived threats to national security, it might be expected that human rights will be quickly cast aside. In some cases this is true, but it is not always the case. The Siracusa Principles (UN Commission on Human Rights 1984) seek to guide authorities in striking the right balance, setting out the conditions under which it is permissible to derogate from the International Convention on Civil and Political Rights— including in cases of public health emergency (see Amon 2014). The principles require, amongst other things, that any such derogations to be based on legal procedure, be evidence based, and be the least intrusive means available, and for there to be a right of appeal. Although non-binding in terms of international law, these principles nevertheless set standards against which national policies during outbreak emergencies can be tested and a guide to how conflicts between security and human rights/civil liberties can be resolved. There is also evidence that disease control policies that unduly infringe human rights and civil liberties can be less effective. During the 2014 Ebola outbreak, for example, there was at least one case of a ‘breakout’ from an enforced quarantine facility as a result of distrust of the motives of the authorities. In pure public health security terms, ‘social distancing’—separating individuals who have a disease (or who are suspected of having a disease but are not yet displaying symptoms) from the rest of the community—can be an effective form of containment. But both ethical and practical considerations weigh upon decision-making, meaning that hard choices often have to be made about how much individual freedom we are prepared to trade for a given degree of security— choices that are often made even more difficult by the conditions of emergency and uncertainty that frequently characterise such situations.

136   Simon Rushton

Travel and Free Trade Similar dilemmas arise over whether to implement travel and trade restrictions in an attempt to prevent the cross-border spread of disease. As discussed in the first section of this chapter, the problem of new diseases being brought into a territory through travel and trade is not a new one, but the increase in international travel that has been characteristic of the globalisation process has, for many, dramatically altered the scale of the threat. If ensuring security from disease were the only consideration, then sealing national borders in the event of an outbreak occurring elsewhere might be an effective response. In the modern global economy, however, few nations would have either the desire or the ability to put in place such drastic isolationist measures. Aside from restricting people’s freedom of movement (as discussed in the previous section), such a policy would have significant economic impacts and could quickly lead to shortages of imported goods. Instead, what is more commonly seen in the case of outbreak emergencies is the imposition of temporary trade and travel restrictions targeted at affected territories, such as those put in place by some neighbouring states of Guinea, Liberia, and Sierra Leone during the 2014–2016 Ebola outbreak and by a number of states against Mexico during the 2009 swine flu pandemic. Again, however, these measures raise both political and practical problems. First, whilst often justified on national security grounds, even targeted restrictions pose problems in terms of global health security. One of the knock-on consequences of the imposition of such restrictions has been that governments dealing with an outbreak on their territory have attempted to keep it secret, to avoid the economic damage caused by restrictions being placed on them. In the SARS case, for example, China initially attempted to cover up the outbreak, hampering the international response and increasing the likelihood of what was at the time a localised outbreak becoming a global pandemic for which the world was unprepared. Cash and Narasimhan (2000) identified this same problem in previous outbreaks. The revised IHRs that were adopted by member states of WHO in the aftermath of SARS (WHO 2005) were intended to address this issue through introducing incentives for open reporting, and disincentives for secrecy. The ‘carrot’ was the promise of a degree of protection against disproportionate travel and trade sanctions; WHO would now advise member states on what restrictions were acceptable, and (in normal circumstances) countries would be expected to abide by those recommendations. The ‘stick’ was permission for WHO to act on reports of an outbreak from non-state actors, making it more difficult for a government to keep a major public health event secret (Davies, Kamradt-Scott, and Rushton 2015). Not only can travel and trade restrictions lead to secrecy; they can actually undermine the response to a major disease emergency. In the case of the West African Ebola epidemic, for example, the UN’s High-level Panel on the Global Response to Health Crises (2016: 18) found that unilateral border closures and trade and travel restrictions caused significant economic losses and hindered the flow of responders and supplies to the Ebola-affected

Security and Health   137 countries. The suspension of flights by several commercial airlines required the use of special humanitarian logistics networks.

What is more, travel and trade restrictions are in any case of dubious efficacy. Measures such as medical screening at ports and airports may have a role to play in identifying infected individuals, but they are by no means foolproof. As shown by the Thomas Duncan case discussed at the beginning of this chapter, such measures can be relatively easily evaded and are unlikely to successfully identify asymptomatic (and potentially unwitting) carriers of a disease. The ‘security theatre’ of border screening may help to reassure a fearful domestic population that something is being done to protect them, but it cannot be relied upon. Indeed, it may even encourage people to find ways of crossing borders without detection, increasing the health risk to themselves and others. Again, therefore, policymakers are required to weigh up the appropriate balance, bearing in mind not only the threat of disease the country faces, but also the economic and political consequences (both domestic and international) of either under- or overreacting in relation to travel and trade measures.

Opportunity Costs Finally, there are trade-offs between putting resources into preparations to meet future disease threats and the opportunity costs of not being able to use those resources in pursuit of other health objectives that might reduce the likelihood of such disease threats occurring in the first place. Do preparations for defending against disease outbreaks (which may not happen, but which are considered a national security risk) take money away from other health areas where urgent needs exist? If, as the Copenhagen School (Buzan, Waever and de Wilde 1998) suggests, the result of securitisation is to prioritise those issues seen as ‘security threats’ above others, then it naturally follows that those not seen as security issues may be under-prioritised in comparison. To take one example at the national level, there have been a number of debates in recent years over the resources and effort put into pandemic preparedness plans (particularly by governments in the West), with disagreements over whether this has been an effective use of resources. Pharmaceutical stockpiles have been one major focus of debate. Countries, including the United States and the United Kingdom, have invested heavily in stockpiles of drugs likely to be useful in future disease outbreaks. This has happened in a context in which general health system expenditure on pharmaceuticals and other medical technologies continues to increase rapidly year after year, with even the wealthiest countries seeing political controversy over rationing of drugs for cancer and other conditions. As a result, some have been concerned that the perception of pandemics as security threats has allowed drugs intended to treat certain types of infections to break free of the financial restrictions that would otherwise apply—even though (given that pharmaceuticals have a shelf life, and the likelihood or nature of future pandemics is unknown) there is a real possibility that the stockpiled drugs may never actually be used.

138   Simon Rushton At the global level, similar arguments have been made that the securitisation of a small group of diseases has had a distorting effect on the overall global health agenda, not least in terms of the allocation of international aid. Pandemics (with the notable exception of HIV/AIDS) are responsible for relatively few deaths globally each year compared to big ‘global killers’ such as ischaemic heart disease, stroke, lower respiratory infections, and chronic obstructive lung disease—the top four on WHO’s list of causes of death worldwide in 2014 (WHO 2014b). Is it right, in that case, that security-related diseases (especially those that are of concern to wealthy Western states) should be prioritised? What are the opportunity costs of doing so? Again, we see the trading -off of investment in addressing potential future health security risks against investment in other things, including other global health problems (Rushton 2011).

Conclusion It is not always clear where public health ends and security begins. The entrance of health issues onto national security agendas, and the collaborations between public health and national security policymakers that have got them there, have made it even more difficult to discern between the two. There are significant overlaps in terminology (including health security, public health security, and global health security). Public health practises have become security practises, and at the same time security policy communities have come to play important roles in public health at both the global and national levels. It is always important to bear in mind that this coming together is not entirely novel; indeed, the historical development of Western public health has been closely entwined with imperial and military concerns. But in the post–Cold War era, disease threats have come to be more central to national security policy than ever before. Whether or not the upsides of this securitisation of health outweigh the downsides is a political question, probably best examined on a case-by-case basis. It is a political question because it involves not only public health efficacy (Are people being protected from disease?) but also what is being sacrificed in pursuit of that protection. Are the right trade-offs being made? Or is too much being sacrificed in pursuit of health security? Careful and critical oversight of both public health and national security policies (neither of which has an unblemished record in respect to issues like human rights and civil liberties) is essential to ensure that the right balances are being struck.

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chapter 8

Gl oba l Hea lth a n d H um a n Secu r it y Robert L. Ostergard Jr. and Jeffrey A. Griffin

Since 1994, when the United Nations Development Programme (UNDP) adopted the human security agenda, the concept has quickly evolved into one of the most expansive and complex policy and research agendas of the post–Cold War era. Whilst the idea itself seemed straightforward—a focus on the well-being of populations instead of the state—the agenda quickly became much more ambitious and unwieldy. At the centre of this agenda was a debate about the role of the state and its relationship to its population. At the extremes, some policymakers and researchers argued that human security was by its nature in a direct relationship to state national security. This argument extended the scope of human security to include an agenda that encompassed practically any issue that posed a threat to the state’s population. Thus, others contended that the human security agenda was virtually meaningless because of its wide-reaching nature. Neither side proved to be prescient in its analysis. The human security agenda instead helped to turn attention to issues that had been ignored by international security practitioners and scholars. Whereas prior to the human security agenda most security approaches revolved around state or systemic approaches to understanding security concerns, the human security approach examined conditions of one of the major cornerstones of the state: its population. However, the attempt to relegate the state to obscurity was theoretically and practically shortsighted. The importance of the state and its capacity to govern is highlighted in the relationship between human security and global health. The approach taken in this chapter is that the state has played a dual role as both a primary threat to and the protector of its population. Weakness in the state’s capacity to assist its population can be just as harmful as the infliction of intentional harm on its and other states’ populations. Whilst global health problems centred on violence, poverty, and infectious diseases present major threats to populations, the state remains the primary bulwark against these threats. Thus, this chapter highlights the distinct background of the human security agenda, its relationship to global health, and the issues

144   Robert L. Ostergard Jr. and Jeffrey A. Griffin that dominate the global health agenda. Global health threats to populations are examined in the context of the importance of state capacity.

The UNDP’s Human Security Framework When compared to the main body of international relations and international security research, the concept of human security is relatively recent, though the concept itself is not new. As Rothschild (1995) argued, the idea of ‘common security’ or ‘human security’ characterised state security from the mid-seventeenth century to the time of the French Revolution; the military sense of the idea of security dates from the Revolutionary and Napoleonic Wars (Rothschild 1995, 60–61). In contemporary times, the UNDP brought the issue of ‘common security’ to the forefront in 1994 when it introduced its new focus on a people-centred approach to security: human security. Conceptually, human security contained two major components: freedom from fear, which encompassed freedom from violence and abuse, and freedom from want, which encompassed freedom from chronic conditions and threats. With the signing of the Universal Declaration of Human Rights in 1948 and the International Covenant on Economic, Social, and Cultural Rights (ICESCR) in 1966, the United Nations clearly emphasised first-generation human rights focused on freedom from fear over second-generation rights that emphasised freedom from want. (UNDP 1994, 24). This was understandable given the emphasis on physical integrity and political rights following the atrocities of World War II. During the decolonisation period of the 1960s and 1970s, however, issues of economic and social rights became more prevalent, particularly in the context of the postcolonial states’ development agendas. In 1994 the UNDP turned its focus to the developmental problems that a large portion of the world’s population had faced for nearly three decades since the ICESCR. The UNDP highlighted four essential characteristics of the human security agenda that incorporated both the freedom from fear and freedom from want concepts. First, human security was a common concern for all. People around the world face common threats that transcend state and regional divisions such as ‘north-south’ or ‘developed’ and ‘developing’ countries. Unemployment, crime, pollution, drugs, and human rights violations all exemplify population threats that are not just problems of the developing world; they are problems of people globally. Second, human security issues are interdependent and transcend state boundaries. For more than 350 years, the Westphalian system of sovereign states emphasised state independence, whereby security stressed protection from external interference by other states. In the context of the human security agenda, however, territory does not limit conditions that threaten freedom from fear and freedom from want. Leaders cannot consider famine, floods, pollution, terrorism, ethnic disputes, and epidemic diseases isolated events, confined to a constructed state

Global Health and Human Security   145 boundary system that people and nature easily ignore. Third, human security is easier to ensure proactively through early prevention rather than reactively through later intervention. In a simple cost-benefit analysis, the costs of preventive measures are often less than the costs of a post-event calamity in the aftermath of a security breach. For example, rather than trying to stem the tide of death and developing emergency plans of containment of a pathogenic outbreak, prior emphasis on primary healthcare or other preventative measures may lessen the potential damage to a state’s capacity or population. Fourth, human security focuses on the status of people. It is concerned with how people live, what choices people have available to them, and which of those options they may choose. Human security also has relevance for the opportunities people have available and whether people live in conflict or peace, freedom or fear (UNDP 1994, 22–23). The UNDP also listed specific dimensions in which human security may be threatened: economic security, food security, environmental security, personal security, community security, political security, and—crucially for this volume—health security (UNDP 1994, 24–25). These elements emphasised the freedom from want element and drew conceptual connections to the capabilities approach that Amartya Sen advanced in his research (Sen 2001).1 From the outset, the conceptual framework the UNDP advanced met with both celebration from supporters and scepticism from detractors. The UNDP created some of these problems with its initial framing of the report, which first ­discussed the broad conceptualisations of human development (UNDP 1994, 13) before introducing its new emphasis on human security. On the surface, the negligible distinctions amongst human development, basic human needs, and human security left some to proclaim that human security was nothing new, Whilst others worked to clarify the conceptual distinctions amongst the related areas (see, e.g., Gasper 2005). However, the overall reaction was either to attempt to expand the conceptual framework for human security or to clarify its conceptual and policy implications. In the process, Whilst the human security agenda did not start as a movement to bypass the state, a body of research formed that relegated the state to obsolescence, Whilst deeming the state itself the primary threat to human security (see for instance Linklater 2005). The position was not necessarily unreasonable; as Buzan pointed out, the state and its population have a relationship wherein people are threatened by the state and other states threaten people through the state (1983, 364). But both these critical approaches to the state miss the paradoxical issue at hand: though the state may threaten the human security of its own population, it is also supposed to be the primary guarantor of the population’s security. Human security as a framework has not reconciled this dichotomy well. Perhaps the most problematic discourse surrounding human security has been in the context of the human security-national security nexus. As Kofi Annan argued: Human security, in its broadest sense, embraces far more than the absence of violent conflict. It encompasses human rights, good governance, access to education and health care and ensuring that each individual has opportunities and choices to fulfil his or her potential. Every step in this direction is also a step towards reducing poverty, achieving economic growth and preventing conflict. Freedom from want,

146   Robert L. Ostergard Jr. and Jeffrey A. Griffin freedom from fear, and the freedom of future generations to inherit a healthy natural environment—these are the interrelated building blocks of human—and therefore national—security.  (UN Secretariat 2000)

Based on Annan’s conceptualisation, human security became ipso facto national security, a problematic association that has continued to plague the human security paradigm. The Secretary-General had directly connected human and national security whilst unwittingly highlighting the conceptual problems that have followed the human security agenda. Annan’s linkage did little to clarify the human security agenda; on the contrary, it resulted in confusing its initial conceptual issues. Given the extent of his claim, there was virtually nothing that could be ruled out as national security. Researchers further muddied the human security waters by expanding the conceptual framework to include arguments that ranged from those that merited serious discussion, such as global epidemics, to those that did not merit consideration, such as  whether rhinoceros poaching constitutes a security problem (Humphreys and Smith 2014). Such overreach ignored the reality of differential state capacities whilst also bypassing the issue that the state was, and still is, the central actor in the inter­ national system. The attempts to clarify this conceptual fuzziness occurred in the form of a scaling back and narrowing of what appeared to be an overly grand agenda for human security advocates. MacFarlane (2004) emphasised the lack of a specific objective in the human security agenda, noting that such a broad agenda makes it difficult to prioritise specific policies. Buzan echoed this strain of thought whilst highlighting the problem of collapsing two distinct agendas: ‘The idea [of human security] also risks mixing up the quite different agendas of international security, on the one hand, and social security and civil liberties, on the other. There is certainly a case for studying the interplay between the international and domestic security agendas, but my concern is that human security aims more at collapsing them than at opening up their relationship’ (Buzan 2004, 370). But even Buzan’s analysis is dated in an oversimplified dichotomy between domestic and international politics rooted in the long evolution of security literature that denied domestic politics mattered for international relations (see, e.g., Waltz 1979). The relationship between human security and national/international security presents a rich field of inquiry for understanding how the two security dimensions are related. The human security agenda, similar to the human rights agenda, is an aspirational framework. Governments bring distinct problems to bear upon their populations either through direct assault on their own populations (or other populations) or through the lack of capacity that governments possess in confronting problems their populations face daily. The former is an issue of human rights and international law; the latter is an issue of both political and economic development that has, ­unavoidably, the state as the primary provider of security to its population. Thus, the paradox of the state and its population is at the centre of the security nexus between human and national security.

Global Health and Human Security   147

Human Security and State Capacity Whilst some policymakers and scholars sought to advance the human security agenda, others highlighted the contradictions present in the juxtaposition between the state and its population. How can populations be secured whilst bypassing the state and its security? Fukuda-Parr and Messineo highlight the issue: ‘The Commission on Human Security [discussing broad versus narrow conceptualisations of human security] . . . emphasises the involvement of multiple actors beyond the state—NGOs, regional organisations, civil society in managing human security, and empowerment of people as an important condition of human security and emphasise that state security and human security are “mutually reinforcing and dependent on each other”’ (2012, 6). To put the issue more succinctly, the capacity of the state affects the security of its population, Whilst the security of the population affects the capacity of the state. Just as important, however, it is also the case that certain problems transcend the basic tenets of the state (territory and population), and the ability of the state to contain these problems is limited by its capacity. At its foundation, the state is comprised of population, territory, and a government. The research on state capacity has tended to coalesce around governments having multiple capacities that must be fostered and perpetuated to secure all three state components. Thus, we can think of state capacity or ‘good governance’ as having four dimensions (Grindle 1996; also cited in Kjaer and Hansen 2002): • Institutional capacity refers to states having agreed-upon rules that orchestrate political and economic activity, Whilst also having an agreed-upon method to enforce them. Whilst this may be a subset of other areas of capacity, it is critical that the institutional mechanism be in place before the actual policy implementation process can occur. • Technical capacity is the ability to formulate and manage macroeconomic policies. Those policies must meet the expectations of the population, promote the welfare of the citizenry (including securing economic development), and acquire the resources to operate the government. • Administrative capacity describes effective administration of basic government infrastructure for development and social welfare—that is, bureaucracy. • Political capacity entails effective and legitimate outlets for social demands, representation, and conflict resolution, conducted by competent leaders and administrators. The state’s legitimacy and its institutions are the focus, but so is the government’s ability to protect the citizenry through institutions such as the military (Grindle and Thomas 1991). Holistically, state capacity captures the capability of governments to carry out specific governmental functions that embody some of the core elements of human and traditional

148   Robert L. Ostergard Jr. and Jeffrey A. Griffin security. These elements include survival, protection of its citizens from physical harm, economic prosperity and stability, effective governance, and territorial integrity. State capacity is not observable, but its preconditions and consequences can be observed— such as economic growth, the character and nature of policy outcomes, or the system of revenue extraction (Kjaer and Hansen 2002, 7). Perhaps the most basic precondition for state capacity is the ‘state’s’ population. Threats to the population affect all population-centred functions, such as economic activity, administration, civil order, and other government functions. Some of those state functions are related both to issues of human security and to national and international security. Nonetheless, all national governments contend with these issues routinely. Some governments perform better than others at handling them because they have a stronger capacity to do so. In high-income, liberal democracies, it may mean weighing an action against the potential electoral ramifications of actions the government may take or not take. For other nations, the issue may even be balanced against the survival of the regime itself (the danger of so-called failed states). Regardless of the circumstances, most government action concerning human security is reactive, because many of the problems cannot be anticipated in either duration or scope, or the threat is so far away temporally that it is difficult to garner attention. As Figure 8.1 illustrates, the state faces security concerns and threats domestically (from its own non-recursive relationship with its population) and from exogenous threats outside of that relationship. Likewise, other states, because of the growing interdependence of nations, also face threats, not just from other states, but also from issues that their own populations face when the nation cannot contain threats within its own borders. When scholars, policymakers, and practitioners classified HIV/AIDS as a national and international security threat, the disease had moved from

State A Population

State A Government

State B Population

State B Government

Figure 8.1  State and population security threats.

Global Health and Human Security   149 one state population to the next whilst undermining states’ capacity to govern. Whilst HIV/AIDS never became an existential threat to states, it was certainly an exacerbating factor in nations that had a weak institutional capacity in their own governance (Ostergard 2002, 2007; Elbe 2006; McInnes and Rushton 2010; McInnes 2006). The traditional security perspective has always relied on a relative framing of the state’s military capacity: How powerful is state A compared to state B? Can state A protect itself from an attack by state B? Whilst Buzan delineates security at three different levels—individual, state, and system—he argues that the focus of international security studies should be on the latter two, because security is the protection of the human collective, not of the individual (Buzan 1983, 50–51). It is clear that human security problems are problems based not on the relative capacity of states, but on the absolute capacity of a state to contain a nontraditional threat. Without the state’s capacity to contain the issue in the non-recursive relationship with its population, other states and their populations may be affected. Nonetheless, the three levels—individual, state, and system— are not divorced from each other. Thus, it is when the human security issue moves beyond the perception that the state can control it that the security dynamic changes. Whilst these threats may emanate from states’ poor capacity to provide for their populations (human security issues), it is also the case that these human security issues may grow to be problems of concern or threats to the states themselves (the non-recursive structure of state and human security) and other states. Likewise, in the context of global health, the health problems found in one state do not always remain the problem of that state. The nature of global health problems has the potential to transcend the traditional Westphalian state boundary system, whilst overwhelming many states’ capacities for contending with these problems.

Global Health and the Commission on Human Security The idea for the Commission on Human Security evolved from the 2000 UN Millennium Summit and was an initiative of the Japanese government. It marked the first significant attempt to reconcile the new and traditional vulnerabilities that states had been facing for years. New or emerging threats such as ethnic conflict, epidemics, and economic instability were couched in the fears that current state and multilateral institutions did not have the capacity to cope with these problems. The emphasis for the commission was on protecting people from these acute threats whilst empowering them to take command of their own lives (Ogata and Sen 2003, iv–v). If human security is structured as a framework to understand and prioritise security of and for individuals, health is both an instrumental and essential concept for its utility. If health is understood as generally ‘the state of being free from illness or injury’, or as Ogata and Sen (2003) contends, as ‘not just the absence of disease, but as a state of

150   Robert L. Ostergard Jr. and Jeffrey A. Griffin complete physical, mental and social well-being’, then health is both directly and indirectly related to the nature of human security. Ogata and Sen (2003) strongly affirm this linkage and argued that ‘health security is at the vital core of human security—and illness, disability and avoidable death are “critical pervasive threats” to human security’ and note that the two concepts are ‘inextricably linked’ (2003, 96–97): Good health is instrumental to human dignity and human security. It enables people to exercise choice, pursue social opportunities and plan for their future. A  healthy child can learn, grow and develop. An adult cured of tuberculosis can resume work to support the livelihood of her family. Saving a child’s life can secure the future generations of a family. The absence of good health can result in enormous grief (the loss of a newborn or young child) and can precipitate an economic catastrophe for the family (the sudden death of a working adult). (Ogata and Sen 2003, 96)

More broadly, Ogata and Sen suggest that four conditions influence the relationship between health and human security: ‘the scale of the disease burden now and into the future, the urgency for action, the depth and extent of the impact on society, and the interdependencies or “externalities” that can exert ripple effects beyond particular diseases persons or locations’ (Ogata and Sen 2003, 97). Given these criteria, Ogata and Sen posit that three health challenges specifically highlight this linkage: violence and crisis, poverty-related threats to societies, and global infectious diseases. These three areas are not exclusive of one another; in fact, these areas are highly interrelated within the complex social structures of states and societies.

Global Health and Violence Global health scholars have had a difficult time situating a human security focus within traditional boundaries of international relations, as the primary focus within the discipline has been on violence between states. Even then, international relations’ research has questioned the relative importance of the state, with the notion of the system of states being omnipotent to explain how states behave. Thus, the focus for international relations for more than two millennia has been on trying to explain macro-level ­violence, with the normative goal being not to repeat history’s most devastating global conflicts. Whilst war is still a relatively rare phenomenon, the concept of violence in international politics has expanded significantly in the human security agenda, with the conceptual expansion reflected in the focus on violence within and between populations and not just state-to-state violence. This approach also meant that the discussion about violence had to move beyond just macro-level theories of war (such as trade and democracy and their relationship to conflict) to meso- and micro-level theories that affect populations. In the context of human security, violence has a central role in making people insecure at state (macro), societal (meso), and personal or interpersonal (micro)

Global Health and Human Security   151 l­ evels. The World Health Organization (2002) has categorised violence into three types: collective (macro and meso levels), interpersonal, and self-inflicted (the latter two both being micro level). “Collective violence” refers to violence inflicted by larger groups (including states), whilst interpersonal and self-inflicted violence occurs at the individual level. Each of these is an important factor in understanding the relationship amongst conflict, health, and human security. However, as Iqbal notes, whilst some research has examined the political and economic consequences of conflict, comparatively little is known about the relationship between conflict and health (2006, 634). At the macro level, the costs of conflict associated with health are both direct (i.e., conflict deaths) and indirect (e.g., damage to infrastructure, hospitals, water and sewage treatment, and refugees). Whilst large-scale interstate conflicts have generally been on the decline, intrastate conflict has been the dominant form of conflict in the post–Cold War era (Gleditsch et al. 2002). The complexity of these conflicts may lead to a greater probability that the conflict can spill over to other states within a region. Moreover, the relationship between conflict and health is bidirectional; conflict can cause a deterioration in health, but health emergencies can cause violence to break out, particularly at the local level. When conflicts spread across borders, they become a problem for second governments, which may lack the capacity to contend with that problem. The spillover of conflict can occur in two ways: through direct involvement or an influx of displaced people (refugees fleeing conflict). The situation with refugees is complex. Refugee camps may lack adequate shelter, food, water, sanitation, and health programs; thus, mortality in the camps can be high (Toole and Waldman, 1993: 500). The lack of personal security and healthcare may create conditions for health problems such as sexual assault, mental health disorders, epidemics, chronic diarrhoea, and a host of communicable diseases (Toole and Waldman 1993; Tinuola and Oriola 2016; Cookson et al. 2015; Reed et al. 2012). However, refugee camps are not disease vectors simply by their presence or their nature. The initial prevalence of disease amongst the refugee population, the level of security in the camp, and behavioural changes amongst refugees may be significant factors in whether disease outbreaks occur in refugee camps (McInnes 2009, 105). The spread of conflict also threatens the physical safety of civilian populations, leading to the most direct health threat emanating from conflicts: the increased likelihood of physical harm, disability, and mortality. Beyond the direct physical threat to individuals, conflict can create humanitarian emergencies that break down often overwhelmed health services. Increased mortality can result not only from physical violence but through the spread of communicable disease and the inability to care for those with non-communicable disease (such as cancer, asthma, diabetes, etc.) (WHO 2002). Conflict has been discussed to this point as a unidirectional relationship in which it exacerbates health conditions. However, it is also the case that health conditions can bring about low-scale forms of violence. The interaction of fear within the population and government’s actions and responses to epidemic outbreaks can create conditions of social unrest that complicate the state’s actions. Historically, outbreaks have embodied the ability to cause societal instability. In the 1830–1832 Russian cholera outbreak, the methods the government used to control the outbreak (including

152   Robert L. Ostergard Jr. and Jeffrey A. Griffin g­ overnment checkpoints) and rumours about how the epidemic started (through intentionally poisoned water wells) led to riots and interpersonal violence in St. Petersburg (Bosin 2009). When an outbreak of plague occurred in 1994 in Surat, India, even though only fifty-six people died, there was so much short-term hysteria that the country experienced massive population flight within just four days—about one-quarter of the city’s population (Huang 2015). The breakdown of public health can also occur during cataclysmic events. Such a situation evolved after the 2010 earthquake in Haiti, which killed approximately 300,000 people and led to over 700,000 cholera cases, as the country’s public health system collapsed under the weight of the earthquake and the spiked demand for medical services. Riots against government and UN relief workers erupted (Tran 2010). The government’s weak capacity to deal with such a cataclysmic event resulted in a massive outpouring of assistance to help the Haitian people and to stabilise the government. A more recent example is the 2014–2015 West African Ebola outbreak. As the epidemic ravaged Guinea, Liberia, and Sierra Leone, the ability of these governments to contend with their respective outbreaks quickly declined. Violence broke out as frightened people attacked healthcare workers and prevented patients from receiving treatment. Thus, the relationship between conflict and health is complex and multidirectional. Conflict also has a direct relationship to poverty, another human security problem. Poverty exacerbates health issues within and between states. It affects the state’s ability to deliver health services and highlights the internal disparity between the wealthy, who can access healthcare, and the poor, who most often do not have healthcare. This problem is not limited to low-income countries but also afflicts high-income countries. Conflict impacts the health problems of the most vulnerable victims: women, children, and the elderly. Women in particular face health problems rooted in their general impoverishment and the cultural biases towards them in many countries. Poverty paves the way for low literacy rates, which impede health knowledge and development of healthcare systems and contribute to high fertility rates, lower life expectancy, higher infant mortality rates, and the greater gender inequalities that promote a general insecurity amongst women in many countries (Boesten and Poku 2009). Importantly, a growing body of empirical evidence finds that gender inequality significantly hinders a country’s ability to develop economically. Gender inequality thus inhibits states from providing needed health infrastructure whilst impoverishing women and forcing them into de­pend­ent relationships that may be harmful to their health. This problem puts females at an increased risk for a broader spectrum of health problems, including prenatal problems and sexually transmitted infections (including HIV/AIDS) (Drimie 2003; World Bank 2001; Gaffeo 2003). On a micro level, interpersonal violence has been categorised as a global health crisis most affecting women. Women’s health issues can reflect the norms and social values that are prevalent within states where they are virtually second-class citizens in their own country. Whilst these values do not necessarily transcend states as part of an escalation or evolutionary process, many states have in common the cultural denigration of women and their status within societies. Women’s unequal rights in marriage, divorce, and inheritance, and their exclusion

Global Health and Human Security   153 from participation in society, politics, educational institutions, and the labour force, decrease their ability to advance and protect their physical and reproductive health, since they have less access to resources and rights necessary to guarantee good health outcomes (Johnson 2008, 145). These problems are aggravated in conflicts, in which women are often victims of sexual violence (WHO 2002; Leatherman 2011; Peterman, Palermo, and Bredenkamp 2011). Whilst the physical effects of sexual violence have immediate consequences for women, the psychological impact over the course of their lives also creates the need for psychological care and counselling, which often cannot be provided within their home states. In some cases that psychological trauma may be linked to health issues that extend beyond the immediate conflict. During Rwanda’s genocide, men claiming to be HIV positive raped women, exacerbating the devastating consequences for these women (Donovan, 2002, s17). Moreover, women in conflict areas often experience reproductive health problems, including a greater number of stillbirths and premature births, more cases of low birth weight and more delivery complications, and longer exposure to chemicals and even radiation from spent ammunition (World Health Organization 2002). Children are just as vulnerable as women in conflict areas. Without access to resources or protective services, children are susceptible to sexual exploitation and physical harm. Poverty can be just as problematic for children in conflict areas as it is for women. Whilst poverty can prevent children from obtaining access to basic healthcare (such as vaccines), conflict, by further hindering access to basic care, can increase danger to them. Barnett and Adger contend that poverty plays a significant role in conflicts in which many of those fighting in militias are youth. Child soldiers face a poverty feedback loop, in which poverty may be a driving force that propels them to violence: ‘A common factor in many internal wars is that armed groups are comprised of young men whose expectations for a better life have been frustrated due to contractions in their livelihoods’ (Ohlsson 2000 cited in Barnett and Adger 2007, 644; WHO 2002). Once the conflict is over, however, the problems for children continue. When children are exposed to violence—personal or collective—their risk for long-term health problems increases. After the conflict children have greater risks for smoking, obesity, high-risk sexual behaviour, and depression, which are also causally related to other major public health problems such as cancer, heart disease, sexually transmitted infections, and suicide (Krug, Dahlberg, et al. 2002; World Health Organization 2002). Moreover, children exposed to these levels of violence may also continue to use violence as a means for conflict resolution, promoting group-level and individual-level cycles of violence (Krug, Mercy, et al. 2002). Whilst women and children are vulnerable in conflict situations, their poverty also exacerbates their susceptibility. Elderly populations are also affected by conflicts and bear a substantial burden during periods of violence. This burden exists when their caretakers lose their lives amid conflict, or more indirectly, as a result of the effects of wider political, economic, and social turmoil. Zimmer et al. (20060 examine the relationship between conflict and its ramifications for the elderly and find that it has long-term impacts. Aside from elderly people dying in conflict, as younger people also die, caregivers disappear, and the elderly are

154   Robert L. Ostergard Jr. and Jeffrey A. Griffin often left without assistance. Moreover, conflict can disrupt specialised medical care and medicinal regimens, whilst driving up medical costs.

Global Health and Poverty As noted previously, poverty and human security are intricately linked. The relationship is also strong in the health aspects of human security. The relationship between poverty and health is not limited to the effects of conflict but is more general in nature. This relationship can be expanded beyond the two vulnerable populations of women and children. The link between poverty and health is straightforward: ‘Poverty and infectious diseases are fellow travellers—each feeding on the other. The poor are at a higher risk of infectious disease, and sickness can deepen poverty, creating a vicious cycle of illness and poverty’ (Ogata and Sen, 2003, 99). The poor are also at an increased risk for non-communicable and ‘lifestyle’ diseases such as diabetes, cancer, and heart disease due to poor diet and lack of exercise. The impact and role of poverty are also broader, with some even suggesting that human security could be measured as the number of years lived outside of generalised poverty (King and Murray 2001). Poverty can be dissected along five capability lines: economic, human, political, sociocultural, and protective (OECD, 2001: 38). Thus, poverty is not just about finances; it is a holistic concept that taps into the dimensions of a sustainable and fulfilling life. The linkage between poverty and health is through the line of human capabilities, where human capabilities is based on health, education, nutrition, clean water and shelter. In general, poorer people suffer from more preventable disease and typically die at a younger age. Globally, poor people carry a heavier burden of disease than wealthier people (OECD and WHO 2003, 19). Disease also negatively affects work production and thus in the long term also hinders efforts aimed at poverty reduction (OECD 2001, 38). Whilst small-scale work interruptions are part of the normal human condition, chronic health problems, such as lifestyle diseases, and sudden outbreaks, such as Ebola, disrupt long-term economic stability at the individual and national levels. In this sense disease has a spiralling relationship with poverty: whilst poverty affects the onset of disease, it is also true that disease reinforces the stranglehold that poverty has on people (OECD and WHO 2003, 19). Infectious diseases can exacerbate poverty in an underdeveloped region if an outbreak occurs. Depending on the type of outbreak, individuals may not have the capacity to work to pay for medical treatment. More drastically, if the parent who provides finances for a family contracts a disease, the family will be forced to find other means of support or risk falling into the cycle of poverty. Ogata and Sen elaborate on this relationship and note that if this situation evolves in a family setting, ‘families are forced to sell their land, tools and other productive assets, to borrow money from relatives and friends and to go into debt to money-lenders. These strains continue even after death . . . health emergencies . . . can precipitate a vicious downward spiral of sickness, compulsory spending, asset depletion and impoverishment’ (2003, 100). Moreover, even national economies

Global Health and Human Security   155 can suffer from extensive outbreaks. The World Bank has projected national economic losses during and long after the Ebola outbreak in Sierra Leone, Liberia, and Guinea at $2.8 billion, as the economic impact will long outlast the period of the outbreak (World Bank 2017). China’s 2013 bird flu (H7N9) outbreak has been estimated to cost $6.9 billion (Nebehay 2013). Chronic epidemics such as HIV/AIDS play a central role in terms of the  ‘vicious cycle of illness and poverty’ that Ogata and Sen highlight: ‘HIV/ AIDS . . . decreases the ability of affected individuals to work and increases their health care costs, resulting in greater financial strain on their households’ (2003, 99). Although this is not necessarily financially crippling in the short term, in the long term health crises such as HIV/AIDS affect the financial health and abilities of families and regions by depleting earnings capacities and decreasing economic productivity. Piot, Greener, and Russell (2007) affirm this: ‘AIDS kills people in the prime of their working and parenting lives, with a devastating effect on the lives and livelihoods of affected households’ (2007, e314). HIV/AIDS also affects more people in poorer countries, because more people live with HIV in low-income than in high-income countries.

Global Health and Infectious Diseases Poverty, though an important factor in global health, is not always at the root of infectious diseases. Infectious diseases may manifest in multiple ways. As such, they represent the final link between global health and human security issues. This relationship cannot be divorced from domestic constraints. The impact of an infectious disease outbreak is contingent upon the nature of the epidemic and the state’s capacity to counter it; sudden onset epidemics generally involve particularly deadly viruses such as Ebola, dengue fever, hantavirus, and Marburg virus. These epidemics often exhibit a high mortality rate; typically afflict a small number of people (though the potential for much greater numbers is certainly significant); and because of rapid responses to the epidemic by state and intergovernmental organisations, have a relatively short life. Policymakers may impose quarantines in a geographic area, but the procedures for dealing with such an outbreak are generally standardised and rarely require new actions. For example, Ebola outbreaks in Uganda in 2000, 2007, 2011, and 2012 were contained through stand­ ard procedures that the Ugandan government and international agencies implemented to contain the outbreaks. The Ebola epidemic in West Africa (2014–2015), however, ran counter to known outbreak characteristics: the epidemic was certainly deadly, but it spread across a wide geographical area and lasted well beyond a year. The inability to contain the epidemic was a direct result of the lack of capacity in international organisations and in the three most affected countries, Guinea, Sierra Leone, and Liberia (although Nigeria did manage to contain it very quickly). The sudden outbreak of an epidemic can create social disruption, public panic, and a broader healthcare breakdown under the stress of high demand. For policymakers the decision to respond is a relatively easy one. The public assumes the state will respond to the crisis, as the state’s leadership would be negligent if such a response did not occur. In conditions of sudden-onset

156   Robert L. Ostergard Jr. and Jeffrey A. Griffin epidemics, the general population may perceive a high level of risk from being near the epidemic and seek to flee or to take other defensive measures. Whilst infectious diseases can affect or exacerbate pre-existing elements of poverty, chronic non-infectious diseases have become more prevalent across the globe and can trap people in a cycle of poverty. ‘Lifestyle’ diseases such as stroke, cancer, diabetes, and obesity all take a personal and national toll. More than fifteen million deaths globally in 2015 can be attributed to heart disease and stroke, with the costs of treating these diseases rising personally and nationally (WHO 2017). When individuals are unable to work due to a lifestyle disease condition, the family suffers from financial constraints that limit the ability to pay for medical treatment. Whilst these diseases have been more prevalent in developed countries, economic development has brought these conditions to developing countries, which often lack the public health infrastructure to contend with them. Thus, the disease burden for lifestyle diseases is on a trajectory for the developed and developing worlds to converge. Chronic, long-term epidemics, however, are more complicated in terms of the type of responses they elicit from states and the population. Chronic epidemics are characterised by several factors: a wide geographic area is affected, many people are afflicted, and the epidemics can last an indefinite period. Whilst the number of people affected may be substantial within a geographic territory, the policy and social response to the epidemic may be anaemic, and in chronic epidemic situations people may go about their lives without much concern for the problem. A combination of reasons may account for the seemingly sanguine response. Some people who live in what could be termed threatening environments may resign themselves to the idea that there is little, if anything, they can do about the lingering threat. They live with the threat, but they try not to let it disrupt their day-to-day lives. In part, people engage in a process of adaptation that allows them to coexist with the health dangers they may face daily. At the same time, people may also adopt a minimalist risk approach, believing that they will not be affected by the problem, that it is a temporary situation, or that ‘it can’t happen to me’ (Rothbart 1970, 110). Whilst people may perceive the threat to others, they will minimise the threat to themselves. These beliefs show a difference between one’s own perceived risk and the perceived risk that one assigns to other people (Sjöberg 1998, 5). This process of ac­cept­ ance and adaptation is a key component of how disease moves from being an epidemic to becoming endemic to a region. The human security problems in both sudden and chronic epidemics are contained within the state’s capacity to deal with an immediate emergency or crisis or long-term health-related problems. Human security advocates have contextualised the inherent dangers of sudden epidemics within the globalisation framework, emphasising that the integration of populations can have devastating effects on large populations in a short period. Such scenarios are not just the fodder for movie plots, but represent a prime example of human security threats and extensions of the traditional security paradigm that focuses on the security of territory, government, and populations. Today, what happens in one state may affect other states to varying degrees. Infectious disease outbreaks have driven the point home to governments in many nations: what happens in your state doesn’t always stay in your state.

Global Health and Human Security   157

Conclusion Human security and global health are inextricably linked, and both issues suffer from conceptual problems that have limited progress. Scholars and practitioners tied the human security concept broadly to the notion of national security, but in so doing they left open a theoretical gap that made all human security issues equivalent to national security issues. Consequently, the human security agenda appeared to be overly broad. However, when the national security issue is parsed out of the human security agenda, and the state is understood as an inextricable actor in the protection of populations, human security is an appropriate and necessary framework for understanding global health. As such, the state’s capacity to deal with global health issues is central to the relationship between global health and human security. The state itself is theoretically important but practically vulnerable to the nature of global health issues. These issues transcend borders, making certain that few global health issues are truly contained by state boundaries. Therefore, absent a state’s capacity to contain issues inside its borders, the interdependent nature of the global system means that human security concerns, and specifically global health issues, will extend beyond a single nation. The West African Ebola outbreak exemplified this problem; the disease burden, urgency, impact, and state interdependencies merged into a perfect storm that rampaged across three West African states, leaving them teetering on the verge of collapse. Whilst there are numerous links between global health and human security, policymakers and researchers have framed three large-scale issues that shape the relationship between the two: conflict, poverty, and infectious disease. The ability of states to contend with these issues is a direct function of their capacity. These issues are also intertwined with and reinforce each other. Conflict has been linked to health issues for centuries, but in the human security agenda, an emphasis on the population helps to highlight the most vulnerable victims of conflict at the macro and micro levels: women, children, and the elderly. Women and children in particular are susceptible to conflict, not just as potential casualties of war, but also in the context of sexual violence, abuse, and interpersonal violence. Conflict often leaves the elderly in dire need of assistance for basic functions and care. Poverty exacerbates the effects of conflict, as the most poor and vulnerable are often the greatest number of victims of not just state conflict, but also interpersonal violence. Likewise, infectious diseases, whether they are sudden or chronic outbreaks, challenge the state’s capacity, as its inability to contain an outbreak may threaten other nations and their populations. Although the evolution of the human security agenda has presented theoretical problems that have hindered the agenda in a theoretical paradox, the human security agenda holds promise for understanding global health issues that extend deeper than the superficiality of macro-state-level approaches. Policymakers and scholars need to realise that the state, for all its problems as a threat to populations, is still the primary driver of international politics and at the forefront of the international community’s response to major global health problems and issues.

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Note 1. Sadako Ogata and Amartya Sen co-chaired The Commission on Human Security.

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chapter 9

Cr itica l Secu r it y Stu dies a n d Gl oba l Hea lth João Nunes

The field of critical security studies (CSS) has emerged over the past two decades through a diverse range of approaches that question the traditional way of seeing security.1 Countering the latter’s almost exclusive concern with military threats and the security of nation-states, critical approaches introduce theoretical and empirical contributions that advance our understanding of what security means, how it has emerged as a central feature in our societies (in topics such as migration, the environment, the economy, and health), and what the implications of our current security-dominated political landscape are. CSS also presents methodological innovations that expand and improve the way we look at security issues. Finally, some approaches within CSS have reflected about how we can promote political change aimed at the alleviation of the insecurity of individuals. This chapter argues that CSS can provide a useful set of tools for understanding global health. It enables rich analyses of how health problems come to be seen as matters of security. It allows us to discern the underlying conditions that make this possible, as well as the (not always beneficial) effects of framing diseases as threats. More broadly, it shows how health security can be conceived of as a layered phenomenon, encompassing not just state and regional stability but also the everyday lives of individuals and groups. This means that the potential of CSS for the study of global health goes beyond the strict remit of ‘security’ and ‘threat’. The field provides an analytical and normative toolbox for identifying, exploring, and addressing the multiple individual vulnerabilities that lie at the heart of global health. The argument begins by contextualizing and laying out the core tenets of CSS. It then shows how some of the core concepts in the CSS literature—namely securitization, risk, and vulnerability—can be applied to the analysis of health issues.

162   João Nunes Finally, the chapter demonstrates how CSS can function as a privileged entry point into the political dimensions—and limitations—of the current global health regime.

Critical Security Studies and the Politics of Security From the 1980s onwards, the field of security studies witnessed great effervescence when some authors began to enquire into the meaning of security (Buzan 1983; Ullman 1983). These contributions challenged the taken-for-granted assumptions of mainstream strategic thinking, particularly its state-centric, Western-centric, militaristic, and masculinist frames. Some scholars endeavoured to go beyond the state as the predominant focus by looking at the security of individuals and societies in sectors other than the military, in what amounted to the ‘widening’ and ‘deepening’ of the concept (Smith 2000). This mirrored the growing influence of post-positivism in the discipline of International Relations (IR), which came out of a broad concern with the nature and construction of knowledge (Booth et al. 1996). For post-positivists, knowledge was not externally validated by reference to empirical ‘reality’, but rather part of an ensemble of interrelated theories, knowledge claims, and social conditions of knowledge production (Lapid 1989). At the same time, IR was also being influenced by Frankfurt School critical theorists, such as Max Horkheimer and Jürgen Habermas, who, advancing the Marxist critique, saw knowledge as socially and politically situated, that is, as deriving from particular political interests. Knowledge was viewed as complicit in legitimizing and reproducing forms of political organization predicated upon the domination of certain groups (Hoffman 1987; Linklater 1996). The joint influence of post-positivism and Frankfurt School Critical Theory gave a sense of coherence and purpose to emerging debates in security studies. Security researchers began to recognize the field as an inherently political site in which knowledge about security is produced and, more broadly, where security practices are imagined and legitimized. It is in this context that one can understand the emergence of CSS, a term first used in Krause and Williams’s (1997a) Critical Security Studies: Concepts and Cases. This volume set out to present an ‘epistemological shift in the way security is to be understood and studied’ (Krause and Williams 1997b, 49). Since then CSS has questioned mainstream security studies by broadening the range of issues (beyond the military sector) and considering other referents (besides the nation-state). It has also presented a radical departure by approaching security as embedded in political processes. Ideas about security do not derive from objective threats that can be observed ‘out there’ in the world. Instead, CSS argues that they are connected with our assumptions about how political communities should be organized and the values we believe should be protected. One example of this is the way in which, in the aftermath of the September 11, 2001 attacks, terrorism was

Critical Security Studies and Global Health   163 represented by some governments as a ‘war’ against the ‘Western way of life’. Terrorism was framed as a particular kind of problem (a war on ‘Western values’), to the detriment of seeing it through another lens (e.g., that of criminal law). CSS starts with the assumption that ideas about what security means and what is threatening are not self-evident; rather, they result from the use of particular lenses that allow us to make sense of issues. Another important innovation is that CSS sees ideas and practices of security as having political implications. Put differently, security is political not simply because it originates from political processes of interpretation, but also because it alters political priorities, helps to legitimize certain practices, and contributes to defining the range of acceptable and desirable policy options in a given situation. To return to the example of terrorism, its framing as an ‘act of war’ contributed to justifying a number of restrictions on rights and civil liberties, visible for example in the PATRIOT Act of 2001. In sum, CSS can be defined as an overarching effort of ‘politicization’ of security (Fierke 2007, 33) that explores the assumptions and social struggles that underlie security understandings and policies, the context in which these are located, and their political implications. Approaches from different theoretical persuasions can be grouped under the umbrella of CSS. These include, but are not limited to, approaches inspired by feminist theory, peace research, constructivism, postcolonialism, Marxism, and poststructuralism. This diversity means that politicization has been pursued in different ways by the contributions to the CSS literature. One approach investigates the socially constructed nature of security and threat. Of particular significance here is the theory of ‘securitization,’ which suggests that ‘threats’ do not exist ‘out there’ as an objective phenomenon identifiable by reference to predetermined criteria; rather, they emerge out of a process in which an issue is presented discursively as an existential threat and is accepted as such by a relevant audience (Wæver 1995; Buzan et al. 1998). Security is therefore ‘intersubjective’—that is, agreed upon among key actors. Building on the notion that threats are socially constructed, other authors have investigated the role of security agencies and professionals, namely the bureaucratic procedures and institutional dynamics that enable the framing of certain issues as threats (Bigo 2002; Huysmans 2006). Yet others have focused on risk. According to this view, a distinguishing feature of the contemporary security landscape is the fact that it is predicated not simply on the framing of issues as clear and present threats, but also on attempts to predict and calculate uncertain and future hazards (Aradau and Van Munster 2007; Dillon 2008; Van Munster 2009). In all of these cases, the construction of security is intertwined with political assumptions about what needs to be protected and what from. This contrasts very starkly with mainstream approaches, which tend to bracket these questions and assume threats to be uncontested realities. Regarding the political effects of security, the CSS literature has also pursued different avenues of enquiry. According to securitization theory, the framing of an issue as a threat to security presents exceptional measures (i.e., the circumvention of normal processes of deliberation) as necessary to counter an existential threat. CSS authors have also highlighted more surreptitious effects by showing how security rationalities can

164   João Nunes permeate everyday life and the routine decisions of those responsible for shaping policy (Bigo 2007). More broadly, security has been said to contribute to defining how political and social relations are organized in a given society. By presupposing ‘a process of political identification’ and by ‘constructing political agencies’, ideas and practices of security ‘open a space within which a political community can represent and affirm itself ’ (Huysmans 1998, 238). By delimiting the remit of what is threatening, conceptions of security also contribute to defining a political community’s identity—often by the identification of threatening others. Finally, some contributions to the CSS literature have provided alternative visions of security. Countering the inherently pessimistic assumptions underpinning securitization theory—which suggests that securitization inevitably results in undemocratic practices, ‘the narrowing of choice, the empowerment of a smaller elite’ (Wæver 2011, 469)—other authors in CSS have conceived security in more inclusive and democratic ways. As McDonald (2012) has argued, security is contested and one must always understand it in context. Assuming from the start that security implies the narrowing of choice and the empowerment of an elite forecloses the acknowledgement of security claims that may seek to achieve exactly the opposite. Indeed, some authors in the CSS literature have advanced emancipatory visions of security, an approach that has been called ‘security as emancipation’ (Booth 2007; Basu 2011; Nunes 2013). Booth, for example, has defined security as the removal (or at least alleviation) of constraints upon the lives of individuals and groups. In his view, security encompasses freeing people from the various forms of oppression—poverty, violence, ill health, lack of education, of lack of political freedom—that ‘stop them from carrying out what they would freely choose to do, compatible with the freedom of others’ (2007, 110, 112). The emancipation-inspired literature conceives critique not merely as the questioning of predominant ideas and practices of security, but also as the development of alternative conceptions that can support political change in the direction of more desirable security policies.

The Critique of Health Security: Securitization and Risk The emergence of health as a global issue in the past few years is inextricably linked with security. The 2001 anthrax attacks on the United States were a pivotal event that placed health squarely within the post-9/11 context of broader security anxieties. For McInnes and Lee (2012), security is one of the fundamental ‘frames’ that currently shape understandings of global health. As a result of the increasing salience of ‘health security’ in the political discourse, security has assumed a central place in academic works on global health. This is particularly true in the discipline of IR. The IR engagement with health developed out of a concern with the impact of diseases on national security, particularly state stability and the preparedness of armed forces—HIV/AIDS being one of the most

Critical Security Studies and Global Health   165 scrutinized cases (Ostergard 2002; Peterson 2002; Altman 2008). Studies have also considered security referents besides the nation-state, with health issues being approached from the standpoint of human security, that is, as threats to the welfare of individuals and groups (Fourie and Schönteich 2001; Chen and Narasimhan 2003). The politicization of security advanced by CSS has made important contributions to our understanding of global health. Engagements of IR with health security have been decisively shaped by CSS and particularly by securitization theory (Caballero-Anthony 2006; Davies 2008; Curley and Herington 2011). Scholars working with a securitization framework take issue with the idea that diseases and other health problems are objectively ‘threats’. Instead, they argue that health problems emerge as security issues because of social processes of representation—which may be explicit or implicit, intentional or not. For example, as McInnes (2016) argued, the framing of Ebola virus disease as a global security threat (during the 2014 outbreak in West Africa) did not describe an intrinsic quality of this virus. Instead, it helped to constitute Ebola as a certain kind of problem (namely, one that threatens the integrity of society and the state) requiring certain kinds of solutions (such as the intervention of the military). In addition, securitization theory also enables us to recognize health security as a mechanism for the legitimization of policy. In this context, critique proceeds by investigating how health security can shape politics by helping to justify policy agendas, break deadlocks, alter priorities, or garner resources. The critical perspective serves here as a reminder of the pitfalls of mobilizing security when making sense of, and responding to, health problems. Invoking a security vocabulary or rationality when framing health issues may trigger or serve to justify questionable emergency measures such as travel restrictions, quarantines, or forced inoculation campaigns. Even when security is not explicitly invoked, its effects for global health can still be felt. Here, insights from CSS—namely the literature on risk—are useful when seeking to make sense of recent developments. The concept of risk is commonly used when speaking about health and other issues (such as the environment or the economy), but its deeper layers are often overlooked. The CSS literature has sought to remedy this by providing a more nuanced engagement with risk. Elbe (2008, 186) has suggested that risk should be seen not simply as a potential hazard, but more fundamentally as ‘a particular method of breaking down, rearranging and ordering reality’. Looking at the case of HIV/ AIDS, Elbe argues that a risk mentality oriented toward the calculation of an uncertain future opens the way for the deployment of a new form of normalizing power by states and other global health actors. Through this power, ‘populations are subject to continuous indirect surveillance and . . . those groups deviating from the desired biological norms (such as being HIV-negative) are targeted by a variety of political interventions’ (Elbe 2008, 195–196). The notion of risk thus allows us to discern how security can assume more surreptitious—but no less problematic—dimensions in relation to health. Elbe’s critical approach points to the pitfalls of relying on risk as a rationale for health policy. This is a pertinent analysis at a time when the predominance of a risk-based rationality reveals ongoing shifts in global health norms and governance mechanisms. An example of this is the legal status of the ‘public health emergency of international

166   João Nunes concern’ (PHEIC) under the 2005 revision to the International Health Regulations. PHEICs were declared by the World Health Organization (WHO) in relation to the international spread of poliovirus in 2014, the 2014 Ebola outbreak in West Africa, and the 2015 Zika virus disease outbreak. For Weir and Mykhalovskiy (2010, 126), PHEIC is an important development in global health governance because it signifies a ‘fundamental shift from surveillance of the certain to vigilance of public health risk’ in the form of uncertain and unexpected events. This shift has resulted in the use of resources in the name of a precautionary principle, rather than in response to a clear and present health problem. While in some cases a precautionary approach can be important to prevent crises, it can also lead to the skewing of priorities to serve other agendas, such as media or corporate interests. The spread of the Zika virus is a good example of the pitfalls of a risk-based mentality. In this case, the declaration of a PHEIC was not based on what was then known about the virus. For the Emergency Committee advising the WHO secretary general on Zika, the decision was taken on the basis of ‘what is not known about the clusters of microcephaly, Guillain-Barré syndrome, and possibly other neurological defects’ (Heymann, Hodgson, Sall et al. 2016, 719). In other words, the emergency was not the Zika virus in itself, but rather the uncertain association between Zika and other disorders. For a few months in 2016, Zika was the most prominent item on the global health agenda, commanding an enormous amount of media scrutiny and public attention. However, the focus on Zika contributed to the neglect of other (interconnected and arguably more pressing) health emergencies. In Brazil, the epicenter of the Zika outbreak, the Zika epidemic is part of a broader and intractable problem with mosquito-borne diseases. In  2016 the country reported 211,770 probable cases of Zika infection. What remained largely unreported (at least in the global North) was the fact that in the same period Brazil also reported around 1.5 million cases of dengue fever and at least 609 dengue-related deaths (Secretaria de Vigilância em Saúde—Ministério da Saúde 2016). Also in 2016, Brazil reported 263,598 cases of chikungunya (with 159 confirmed deaths). Both dengue and chikungunya are transmitted by the same mosquito that transmits Zika. Yet the PHEIC declaration meant that all eyes were turned to the latter. Thus, while in some cases securitization and the mobilization of risk may be useful to draw attention to health problems, they can also contribute to obscuring other important issues. Equally important is the quality of attention that is produced once one adopts these prisms. Security framing is potentially conducive to a superficial engagement with health problems. It helps to legitimize an emergency mode of response focused on containment and crisis management, which may narrow the range of policy options and foreclose medium- and long-term interventions. The case of the recent Ebola outbreak in West Africa reveals the extent to which framing an issue as a security problem—and thus as a crisis needing an immediate fix—can lead to the privileging of short-term measures and to the neglect of the long-standing structural problems that allow crises to emerge (Nunes 2016). In sum, a critical approach is committed to thoroughly examining the political implications of health security. This entails scrutinizing the specific policies enacted in the

Critical Security Studies and Global Health   167 name of security, asking how they are being legitimized and whether they put pressure on democratic procedures, civil rights, and liberties. It also entails looking at the ways in which security shapes the political sphere more broadly, by helping to organize political communities around ideas of who/what is threatening, who/what should be protected, and how. CSS enables us to highlight the sometimes problematic nature of policy countermeasures to health issues. It also shows that the framing of certain problems as health threats can lead to the neglect of other important questions and contribute to perpetuating the very conditions that create those problems in the first place.

Health Insecurities: Addressing Vulnerability The preceding discussion reveals that a critical approach to health security is a normative endeavour. Approaching health security in a critical manner entails not simply an analysis of how health threats emerge and with what consequences, but also some sort of judgement (even if only implicit) about the desirability of using security when seeking to understand and deal with health problems. Given the preponderance of the securitization perspective in CSS, this normative component has overwhelmingly been shaped by a profound scepticism toward the virtues of security. Health security tends to be identified with the militarization of response or with other equally dangerous and problematic measures of an exceptional or undemocratic nature. In this context, the critique of health security is associated with the problematization of existing policies, that is, with an effort to challenge their legitimacy and to question the very presence of security in responses to health problems. However important this problematization might be, it would be reductionist to view the critique of health security only in this way. On the one hand, this understanding of critique is aimed predominantly at the nation-state and other powerful actors that are able to undertake securitizing moves. It risks overlooking the fact that insecurity—lack of assurance, predictability, or certainty—in relation to one’s own present and future health is a daily reality for millions of people. For example, a government’s securitizing moves in relation to the preparedness of its armed forces in the face of a high HIV/AIDS prevalence are different from the anxieties experienced by an individual unable to access antiretroviral treatment or by groups exposed to stigma, discrimination, and violence because of their HIV status. The critique of health security needs to be able to appreciate the different meanings that ‘being secure’ can have in the case of health and should reorient its attention toward addressing the insecurities experienced by individuals and groups. On the other hand, when conceived in a limited way—that is, when focusing exclusively on the problematization of elite discourses and practices—a critical approach runs the risk of presenting a deterministic reading of the political effects of health security.

168   João Nunes The pursuit of health security does not necessarily imply undemocratic measures or the sacrifice of rights and liberties. When seen through the perspective of individual and group experiences of insecurity, it can actually mean the opposite: the broadening of democratic scrutiny on health policymaking, a more participatory debate about health provision, and the expansion of rights. The critique of health security thus needs to be able to consider situations in which the pursuit of security—or rather the alleviation of insecurity of individuals and groups—is a good to be aimed for. Thinking about security along these lines is key to one of the most important approaches in CSS, namely security as emancipation. This approach distinguishes itself by zooming in on insecurity as an experience of individuals. Insecurity has a bearing on the inability of individuals to influence in a meaningful way the course of their lives. Individuals who are more secure are able to think and act in matters pertaining to their lives, free from social constraints such as physical aggression, political persecution, poverty, or ill health, as well as from the broader structures and relations in which these constraints emerge. In this way, it becomes possible to approach health insecurity not simply as the experience or threat of illness. Health issues can be considered matters of security if they restrict in a decisive manner the ability of those involved—individuals, families, and/or groups—to shape the course of their lives. Crucially then, this is not a question of the seriousness of the illness, but of its ability to impact the lives of those affected. For many people the simplest health problem can be a major constraint and even a watershed; someone in a precarious job, for example, may run the risk of being made redundant after calling in sick because of flu or an upset stomach, which in turn may significantly affect their own quality life and that of their family. This approach to the critique of health insecurity has at its heart the concept of vulnerability, inasmuch as it focuses on the identification and redressing of concrete health vulnerabilities. What does it mean to ‘be vulnerable’ in the case of health? Vulnerability can be defined as a group’s or an individual’s susceptibility to harm. In its most basic sense—that is, as the possibility of being harmed—vulnerability is an intrinsic part of being human, because we are all connected to and dependent upon others, in addition to being exposed to natural hazards. As Butler (2004, 31) has argued, vulnerability follows from the inherently social and political nature of embodied life, from the fact that we are ‘attached to others, at risk of losing those attachments, exposed to others, at risk of violence by virtue of that exposure’. However, this does not mean that this fundamental bodily vulnerability is experienced in the same way by everyone. For example, although we all require food and water throughout our lives, factors such as gender, age, or disability may impact our specific experience of this vulnerability. Whereas in some countries access to clean water is taken for granted and is as straightforward as turning on a tap, in many regions of the world the procurement of safe water is an almost insurmountable task. Bodily vulnerability therefore intersects with the social, political, economic, and environmental context in which individuals and groups find themselves. Vulnerability may be an intrinsic part of what ‘being human’ means, but not everyone is vulnerable in the same way. Vulnerability becomes a matter of insecurity when it assumes a systematic character. Vulnerable individuals or groups may be deemed insecure when they are structurally

Critical Security Studies and Global Health   169 positioned in a way that makes them more prone or likely to be harmed. However, the relationship between vulnerability and harm is not a straightforward one. It is not simply a question of vulnerability leading to harm, but also a case of vulnerability being reproduced by harm. Take, for example, the case of uninsured individuals who see their lives disrupted by an accident resulting in substantial medical bills, and who therefore end up with additional vulnerabilities (such as homelessness). Moreover, in addition to being a condition of susceptibility, vulnerability also encompasses a relative lack of capacity to ‘bounce back’ from harm when it does occur. For example, people who are more susceptible to being infected with parasitic diseases are often the least able to adequately deal with some of the debilitating consequences of these diseases. As a result, what in other circumstances could be addressed with relative ease ends up having an inordinate impact. Wolff (2012, 76) has engaged with this question by way of the concept of resilience, which he associates with the capacity to overcome the consequences of ill health as well as the ‘costs and difficulties of taking steps to mitigate those consequences’. When thinking about health vulnerabilities, it is also important to distinguish between actual vulnerabilities—that is, those that require immediate action—and potential vulnerabilities, or those that require long-term interventions. Mackenzie, Rogers, and Dodds (2014) have recognized this by distinguishing ‘dispositional’ from ‘occurrent’ forms of harm. Not all sources of vulnerability translate into actual harm, but one must be aware of existing vulnerable dispositions, that is, of individuals or groups who are socially and economically positioned in such a way that they may be adversely and inordinately affected by particular actions or inactions. This applies even if those actions or inactions are geographically and temporally removed. For example, the 1984 Bhopal industrial disaster had an immediate impact on the lives of hundreds of thousands of people who were exposed to the leak of dangerous gases. In this case, there were immediate vulnerabilities, which were intrinsically connected with economic conditions because those living close to the industrial facility were poor. As Mukherjee (2010, 29) has argued, ‘[t]he factors that made the poor vulnerable were class specific: poverty, illiteracy, poor sanitation, crowded and ill-constructed dwellings, and total dependence on the state’. However, the Bhopal case also brought attention to the perpetuation of potential vulnerabilities surrounding unsafe and poorly maintained industrial facilities and to how the actions or inactions of transnational corporations threaten the lives and well-being of people who are unable to predict or control existing threats to their health. While it may be right to prioritize immediate vulnerabilities because these constitute sources of immediate harm, potential vulnerabilities need to be included in policy calculations and accountability mechanisms. The engagement with health vulnerabilities afforded by CSS goes even further by shedding light on the relational element. In this sense, vulnerability concerns relations between groups, their relative positions in society, and their different abilities to deal with detrimental events and shape outcomes. Social relations go a long way in determining the extent to which people are exposed to harm. They also determine the extent to which people are able to bounce back from harm when it occurs or will find themselves in a ‘vulnerability trap’ in which harm breeds further vulnerability. This relational

170   João Nunes view of vulnerability was advanced by Robert E. Goodin, who departed from the idea of vulnerability as simple susceptibility to harm because this leaves out important issues regarding causation, agency, and power. In his view, one is not simply vulnerable but rather ‘always vulnerable to particular agents’, who are capable of exercising choice ‘over whether to cause or to avert the threatened harm’ (Goodin 1985, 112). In other words, vulnerability does not simply exist; it is caused by people, and inflicted upon other people, as a result of social processes. Vulnerable people have a reduced capacity in relation to others, who may instrumentalize these power inequalities with exploitative purposes. Mackenzie, Rogers, and Dodds (2014, 9) have pursued this insight by arguing that vulnerability should be seen as a power-laden phenomenon stemming from ‘morally dysfunctional or abusive interpersonal and social relationships and socio-political oppression or injustice’. Vulnerability is thereby embedded in a structural context in which certain individuals or groups are placed in a position of subordination, disadvantage, or exploitation in relation to others. On the basis of this relational understanding of vulnerability, critical security scholars can provide a sophisticated engagement with the health insecurities of individuals and groups. They can do so, first, by recognizing the deeply contextual character of insecurity, a bodily experience that can be situated along a spectrum ranging from grievous harm or death to systematic uncertainty or inability to have some degree of control over one’s own surroundings. Second, when deployed as a critical tool, vulnerability sheds light on the processes through which people become vulnerable or are rendered vulnerable through the actions or inactions of those in a position to shape outcomes. In addition to being a relational phenomenon, vulnerability is also enabled by structural conditions— political, economic, social, and cultural—that place certain groups in positions of systematic disadvantage in relation to others. This approach to vulnerability re-energizes the normative project of CSS by placing health security back on the agenda as a good to be aimed for—not simply as a potentially dangerous set of practices (as securitization-inspired scholars would argue). It also shows the extent to which CSS is not merely a perspective on health security, but can also become a broad-ranging critique of the status quo of global health.

Critical Security and the Politics of Global Health Although the claim that ‘health is global’ has recently become part of the accepted narrative in the wake of high-profile disease outbreaks (such as H1N1 ‘swine flu’, Ebola, Zika, and the fear of an H5N1 ‘avian flu’ pandemic), global health is the result of a long-term historical process (Brown, Cueto, and Fee 2006; Birn 2009; Cueto 2015). Indeed, its genesis can be traced back to the 1851 International Sanitary Conferences (Fidler 2005). Underlying ‘global health’ is the idea that globalization has brought

Critical Security Studies and Global Health   171 together the peoples and regions of the world, creating a situation in which the world is ‘united by contagion’ (Zacher and Keefe 2008). According to this narrative, the increased flows of goods and people brought about by globalization entail a greater risk of international spread of disease. At the same time, the need for adequate policy solutions has underscored the importance of international cooperation and global health governance mechanisms. The perception of health as a global phenomenon is currently being framed by an essentially apolitical vision of governance, which in turn is underpinned by a belief in the human capacity to develop technical solutions (be they technological, pharmacological, administrative, or bureaucratic) to crises or problems (Cooper, Kirton, and Stevenson 2009). However, global health is much more than a commonality of threat and an increased level of cooperation, the two tropes that have arguably dominated existing policy and academic discourses about the topic. Indeed, these two assumptions can be misleading. CSS can be seen as a powerful instrument for questioning the global health narrative and probing its limits. It has the potential to shed light on the political dimensions of global health, allowing us to go beyond this apolitical narrative. It does so not only by zooming in on security (one of the most prominent narratives in global health), but more importantly by using security as an entry point into broader political and social dynamics that underpin health-related ideas and practices at the global level. Refusing the apolitical or technical narrative about global health is an important first step because the historical trajectory of ideas about health and disease reveals not a tendency toward unity and convergence, but rather the persistence of tension, conflict, and inequality. One example of this is the anxiety in relation to immigrants, foreigners, and those who are or seem ‘different’ because of religion, race, sexual orientation, or some other characteristic—and who are seen either as disease carriers or burdens to the health system (Kraut 1994; Markel 1997; Shah 2001). This anxiety is imbued with security concerns, insofar as political communities are frequently built on the basis of an externalization of threats (Campbell 1998). The framing of foreigners or immigrants as health risks therefore contributes to the creation of political community: it establishes the political ‘self ’ through the perception of a threat from ‘others’. Indeed, as has been suggested by Martin (1994), the quest for protection or ‘immunity’ in the face of infectious diseases supposedly coming from the outside has frequently assumed an important part in the constitution of political communities. In this context, sanitary measures go well beyond medical or technical interventions. Instead, they are fully fledged political instruments through which power is mobilized (Foucault 1977, 195–200). The history of tropical medicine also demonstrates this in the context of colonial relationships (Edmond 2006; Anderson 2006). As this history shows, colonial health practices were traversed by security concerns, which revealed themselves in efforts to contain native populations deemed threatening to white colonizers, for example by the establishment of sanitary cordons (Curtin 1985; Echenberg 2002). This political dimension challenges the idea of global health underpinned by assumptions of a common experience: the ‘united by contagion’ narrative. International health cooperation can be seen as a value-laden terrain, permeated by power relations, in

172   João Nunes which interests and agendas clash (Fassin 2012). The International Sanitary Conferences, for example, were marked from the beginning by a fundamental concern with the protection of international trade. The underpinning purpose of these conferences was not the protection of public health, but rather the definition of common measures that would allow for the cross-border circulation of people and goods to be controlled. Such control was based not simply on the restriction of movement, but more precisely on a triage, that is, on the separation between ‘desirable’ and ‘undesirable’ people and goods. In other words, security and economic concerns were closely intertwined in these early efforts of international health cooperation (King 2002). This logic is still present today, with global health governance being not an apolitical project, but rather revealing the intersection of security, capitalism, and a liberal worldview. Assumptions of neutrality frequently serve to obscure the fact that global health, since its inception and in its contemporary forms, has been a site of exclusion, vulnerability, inequality, and the disadvantage of certain groups and regions. A critical approach to global health is therefore concerned with identifying the political structures and relations that underpin global health governance mechanisms, as well as their ideological assumptions. Here, the conceptual and theoretical tools of CSS are particularly useful, enabling an investigation into the processes through which health-related ideas and practices are advanced, interpreted, justified, legitimized, and contested. The securitization approach, and its emphasis on the intersubjective process through which a health issue is presented as an existential threat demanding emergency measures, is a good example of how a seemingly natural or uncontroversial narrative can be brought into question. Even when presented in a straightforward manner—as in the form of a ‘health security’ narrative—the meaning of global health is socially constructed, ambiguous, and therefore not fixed once and for all. CSS can help us engage with the multiple arenas of signification that underpin global health discourses. A critical approach to global health is also concerned with a second question, that of exploring the political consequences of the processes through which health and disease are made sense of at the global level. In other words, how do these processes impact the definition of ‘necessary’ or ‘desirable’ policies? Given that concepts play an important role in circumscribing the limits of the political imagination, investigating how global health is framed is a springboard toward an examination of the context in which specific policies are defined and executed. Again, CSS can be useful in this regard. Not only does it open fruitful avenues of research into the potentially dangerous implications of certain policies, but it also provides a normative agenda for policy based on the core concern of redressing health insecurities in the form of vulnerabilities. A third way in which CSS is useful in a critical engagement with global health is by opening the way to consider traditionally neglected issues. This may seem counterintuitive because ‘security’ is often associated with high-profile issues: problems that are framed as urgent crises requiring prioritization and mobilization of resources. At first glance, then, a security approach would seem ill-suited to engage with issues that fail to reach the status of ‘threat’ and thereby garner attention and resources. Nonetheless, the focus on the individual and group levels of insecurity, as well as the concern with

Critical Security Studies and Global Health   173 vulnerability, also means that CSS can probe into the ‘hidden’ health insecurities that fail to make it to the global agenda, such as maternal health or inadequate water and sanitation. CSS—and particularly the notion of security as emancipation—is well positioned to engage with issues that normally fall off the radar of global health policymaking. This pertains not simply to neglected diseases, but more broadly to problems that are relevant to health vulnerability (such as neglected determinants). It also pertains to the neglect of particular groups and the way in which these can be rendered systematically vulnerable to disease and excluded from the best available healthcare. Finally, and in connection with the focus on health insecurities as bodily experiences, CSS can be an important resource in the critique of global health by drawing attention to the multiplicity of meanings and experiences of health and disease—not only between but also within countries. ‘Being healthy’, ‘being ill’, or ‘being insecure’ depends on variables such as social and economic status, race, gender, religion, sexual orientation, age, and disability status. These go a long way in determining vulnerability to ill health and the capacity to deal with it when it occurs.

Conclusion CSS offers a multifaceted and potentially fruitful agenda for global health research. It enables one to focus on various political dimensions of health security by inquiring into its assumptions and investigating its impact on agenda setting and policy definition. As CSS shows, ‘health security’ can sometimes be detrimental insofar as it can place pressure on democratic processes or infringe rights and liberties. One of the contributions of CSS is that it provides an important cautionary note about the supposedly benign character of certain health policies. In addition, CSS also offers clues about the deeper political effects of ideas and practices of health: how they help to define political communities on the basis of assumptions about otherness as ‘threatening’ or ‘contagious’. Modern understandings of politics, as well as contemporary forms of political community based on a strict separation between citizens and outsiders, are to a great extent based on anxieties in which security and health concerns are intertwined. CSS helps to bring these issues to the agenda of global health. This also means that the potential of CSS for our understanding of global health goes well beyond the remit of security. It provides tools with which one can question (and eventually seek to redress) problems that are not necessarily framed as security threats. CSS is well attuned to consider both high-profile and neglected problems. By adopting a broad conception of vulnerability, we can recognize the multiple instances in which individuals and groups are being rendered insecure, particularly as a consequence of problems that normally fall outside the global health agenda. More than a perspective on health security, CSS can be seen as a full-blown critique of global health. It asks important questions about the nature of global health; its historical trajectory; its blind spots; and the social, political, economic, and cultural dynamics that determine its winners and losers.

174   João Nunes

Note 1. The author thanks Colin McInnes for his comments and suggestions on a previous version of this draft.

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chapter 10

Biosecu r it y a n d th e R isk to Gl oba l H e a lth Christian Enemark

A myriad of allergies, congenital conditions, physical injuries, mental health disorders, occupational illnesses, and cancers afflict millions of people worldwide. In addition, there are hundreds of types of microorganism (viruses, bacteria, etc.) that infect and sicken humans on a huge scale, especially in poorer parts of the world. These latter, the infectious diseases, many of them contagious, tend to attract a higher degree of public concern and political attention than do the former. Moreover, although diseases lacking a microbial cause are a serious health burden in many places, the sudden outbreak of a deadly infectious disease has a greater capacity to excite the attention of policymakers. In developed countries especially, where populations are less accustomed to infectious disease posing a deadly risk, fear of these diseases is attributable to a combination of factors beyond simply the number of cases or deaths experienced or expected in an outbreak. These factors include a disease’s historical reputation, its gruesome symptoms, the unavailability of effective medical treatment, and the past or potential use of a disease in a biological attack. This last is a particularly powerful factor that compounds people’s visceral fear of involuntary exposure to an unfamiliar and invisible (microscopic) risk, because it seems worse to be deliberately and maliciously infected. Some infectious diseases inspire so much public anxiety and government concern that they are accorded the status of security issues. However, adopting a security-oriented approach to preventing or responding to disease outbreaks is not necessarily a wise move, because security (as a political practice) is not necessarily a good thing. Historically, appealing to security has resulted in many a vital project being funded but also in much money being wasted. Raising security concerns can be a device for maintaining secrecy as well as for increasing public awareness, and a determination to pursue security can result in the perpetration of injustices as well as the achievement of admirable goals. This chapter seeks to show that a particular kind of security practice— bi­o­se­cur­ity—potentially diminishes global health. Biosecurity practices are defined here as government practices aimed at safeguarding the health of human populations within

180   Christian Enemark or across state boundaries against selected infectious disease risks. In the face of such risks, a government’s choice to ‘play the security card’ (Elbe 2011) can often garner extra resources and stronger powers for risk-reduction purposes. Yet such an approach to disease control can sometimes result in protective practices that are counterproductive from a health perspective. The sections that follow show that biosecurity can endanger global health in at least four areas of policy concern: the development of defenses against biological weapons, the management of security risks arising from laboratory research on pathogenic microorganisms, the prioritization of disease risks and response mechanisms as part of an agenda of global health security, and the use of national borders to contain transnational contagion. Other authors have adopted a similarly broad conception of bi­o­se­cur­ity, according to which the natural occurrence of deadly disease outbreaks is considered alongside the deliberate dissemination of pathogenic microorganisms (Collier and Lakoff 2008; Fidler and Gostin 2008). The advantage of doing this, as Gregory Koblentz (2010, 108) has argued, is that it helps ‘make explicit what would otherwise be implicit trade-offs that reduce the risk of one type of biological threat while increasing the risk of another’. In situations that seem to demand the protective effect of a particular bi­o­se­cur­ ity practice, the risk from a health perspective is that such a practice will be more harmful than beneficial. Thus the ongoing challenge for governments individually and collectively is to practice biosecurity in ways that promote rather than undermine global health.

Biosecurity as Biodefense: A Security Dilemma Global health is potentially diminished by any increase in the overall likelihood of biological attacks occurring somewhere in the world. State-based efforts to defend against biological attacks (biodefense) do not, for the most part, present a problem in this regard. For example, accumulating medical supplies and upgrading hospitals’ cap­ acity to treat attack victims are generally not regarded by other states as worrisome activities. However, an international political problem might arise when a government undertakes biodefense activities for ‘threat assessment’ purposes, and here the essential problem is one of offense/defense differentiation. One state’s activities, purportedly aimed at affording protection against pathogenic microorganisms that are deliberately disseminated, might be perceived by the government of another state as having an offensive purpose. And if that suspicion occasioned similar activities (investigations into offensive capabilities) to occur in that other state, the result could be a proliferation of biological weapons and an increasing likelihood of biological attacks as each side continued to compete for technological advantage. One state’s possession of particular technologies, or its conduct of particular activities, might not in fact be intended to threaten another state. But when such a fact is difficult

Biosecurity and the Risk to Global Health   181 to verify, a state that is uncertain of another’s capabilities and intentions is liable to assume the worst and act to bolster its own security. The effect that this security-seeking behavior has on other states—increased concern for their own security—is conceivably unnecessary, and it is counterproductive if it causes those other states to act in ways that confirm or compound prior fears. This predicament of wanting to improve one’s security circumstances but running the risk of achieving the opposite is known more generally in international relations as the security dilemma (Booth and Wheeler 2008). The international suspicion that lies at the heart of the dilemma can sometimes be reduced by material considerations. For example, military capabilities that are geared toward offense are generally regarded as more fearsome than capabilities that are plausibly defensive in nature. So when defensive weapons are clearly different from offensive weapons, it is possible for a state to acquire or accumulate the former without making other states feel less secure (Jervis 1978, 187). In other circumstances and in respect of other capabilities, however, a state might judge that an offense/defense distinction cannot plausibly and safely be drawn. The need to act out of fear would then continue to be felt, and so the security dilemma would remain. In the case of intercontinental ballistic missiles bearing nuclear warheads, for example, there is deep uncertainty about an offensive capability that is supposedly defensive; a state’s defense relies on deterring nuclear-armed enemies from attacking it by threatening a nuclear attack as punishment. Here, it is the status of these weapons as ‘inherently ambiguous symbols’ that materially establishes the security dilemma (Booth and Wheeler 2008, 1). Ambiguity can also be fearsome and dangerous when it comes to biological weapons. One way in which the process of wielding a biological weapon works is as follows: a pathogenic microorganism is chosen, then produced in large quantities through a fermentation process, inserted into a dispersal mechanism, and disseminated in such a way that it survives meteorological conditions on its way to infecting and sickening human targets. The closer a state is to being able to carry out such a process, the closer it is to being in a position to threaten other states. That state could claim that it has placed itself in that position only for the purpose of fully understanding the nature of the threat it faces or might face from other states. However, the problem with experimenting with offensive applications of biotechnology, and with claiming that doing so serves a defensive purpose, is that this puts the offense/defense distinction under great pressure. If all that separates a biodefense program from a biological weapons program is the operator’s intent, other states might be disposed to prepare for a rival’s sudden change of mind by investigating the offensive capabilities they fear; whereas capabilities take time to develop, intentions can change overnight. Security dilemmas in combination could then lead to a security paradox: more offensive know-how all around and more danger of biological attacks against more states. For this reason, it is important for a national government to be sensitive to how its own biodefense activities may be perceived. Of particular concern are certain biodefense activities conducted by the US military for threat assessment purposes which, were they conducted by a rival state, would almost certainly attract US condemnation. A government’s investigation of mechanisms for dispersing pathogenic microorganisms in a particular way and over a wide area can

182   Christian Enemark serve a genuine defensive purpose, such as informing the design or improvement of protective bodysuits and devices for detecting airborne microorganisms. It is also the case, however, that such investigation could guide the planning and execution of a biological attack. As noted in a 1998 US government report: ‘Stabilization and dispersion [research] are proliferation concerns because these technologies increase the efficacy of biological [warfare] agents’ (US Department of Defense 1998). At around the time this report was written, the US government was conducting a number of secret biodefense experiments of a kind that, after their revelation by the New York Times in 2001, raised questions about whether they were geared more toward offense than defense. From 1997 to 2000, for example, Project Clear Vision (sponsored by the Central Intelligence Agency) involved the building and testing of a Soviet-model ‘bomblet’ for dispersing bacteria (Miller et al. 2001a). A number of these bomblets were reportedly filled with simulant pathogens (unable to cause disease) and tested for their dissemination characteristics and reliability under various atmospheric conditions. Experiments in a wind tunnel revealed how the bomblets would fall on targets after being released from a warhead (Miller et al. 2001b, 295). From the perspective of an outside observer, was this an instance of US biodefense activities bringing the ‘biological’ overly close to the ‘weapon’? More recently, biodefense research carried out by the US Army has included the use of various uncontained spaces to explore possibilities for dispersal of biological material. For example, among the ‘tunnel dissemination systems’ at the army’s Dugway Proving Ground in Utah, the Joint Ambient Breeze Tunnel features an ‘overhead, four-zone Sono-Tek nozzle array’, with maneuverable dissemination carts providing for ‘precision set-up of aerosol cloud generation’ (US Army 2012, 44). Here, ‘[p]ortable liquid and dry dissemination systems may be operated for specific tests to replicate an attack (e.g., covert backpack attack), including electric Micronair sprayers and E2 sprayers, Skil® blowers, and puff disseminators’ (US Army 2012, 44). And when a Skil® blower is used to release ‘5 to 10 grams’ of a ‘dry powder simulant’, it creates ‘a concentration of 5,000 to 20,000 particles per liter inside a tunnel’ (US Army 2012, 44). Biodefense work at Dugway’s Lothar Salomon Test Facility includes the use of ‘simulants’ in ‘outdoor studies’ to ‘develop/validate aerosol particle dispersion models to enhance coun­ ter­ meas­ ure response’ (United States of America 2016, 42). For example, simulants used in a 2005 field trial of the Joint Biological Standoff Detection System included a ‘[d]ry killed vaccine strain of Bacillus anthracis [anthrax]’ and a ‘[w]et killed vaccine strain . . . of Yersinia pestis [plague]’ (Buteau et al. 2007, 11). The trial included one late-night dissemination of 20 grams of dry anthrax simulant at a ‘target range’ of 1.2 km and another at a range of 2.6 km, and disseminations of 3.5 liters and 7.0 liters of plague simulant at a target range of 1.2 km and 7.0 km, respectively (Buteau et al. 2007, 37–40). The latter form of experimentation is presumably driven by two assumptions: first, that the systems being tested would be able to detect the dispersal of living bacteria as well as dead ones; and second, that the dispersal mechanisms used to challenge those systems would deliver both kinds of material to the target in the same way. It follows that the operator of the dispersal mechanisms would only need to fill them with real pathogens

Biosecurity and the Risk to Global Health   183 to be in a position to perpetrate a real biological attack. For this very reason, though, the US government would probably take a dim view of similar dispersal capabilities in the hands of a foreign government. Yet if the security dilemma argument presented here holds true, it is also possible that any investigations by other states into offense-capable technology are being driven (at least in part) by a concern to anticipate a US biological attack. From the perspective of global health, this possibility is worrying. With multiple states competing to maintain a technological edge and thus endowing themselves with offensive know-how, the paradoxical consequence of this protective effort might be an increased risk that someone somewhere in the world will be attacked with a biological weapon. Biosecurity in the form of biodefense should not be more trouble than it is worth, so governments mindful of the security dilemma would be wise to avoid experimenting with delivery systems that replicate biological attacks.

Biosecurity as Information Security: Censoring the Findings of Pathogen Research A large-scale biodefense enterprise, even if it is primarily directed toward defending against biological attacks, can also protect human health against infectious disease risks more generally. Government-sponsored laboratory research can lead to vital scientific discoveries about the behavior and properties of pathogenic microorganisms, and the consequent development of pharmaceutical countermeasures (vaccines, antibiotics, etc.) undoubtedly benefits the people who are able to receive them when needed. Nevertheless, it is also the case that laboratory-based pathogen research can itself pose risks to public health, so another form of biosecurity practice is the regulation of scientists’ activities. Unsafe working environments can result in accidental infections and the escape of a dangerous pathogen from a laboratory. Another possibility is that a scientist could steal and maliciously use a pathogen to cause harm. Imposing regulations on scientific conduct protects human health to the extent that this makes such incidents less likely, but the countervailing risk is that a government might thereby end up stifling researchers’ pursuit of discoveries that could one day lead to the saving of many lives. The conundrum, then, is that the securing of populations against selected infectious disease risks can seem to require both the restricting and the facilitating of research efforts. Such efforts include the communication to other scientists (through publication in scientific journals) of information on how experiments involving pathogenic microorganisms were conducted and the results of those experiments. In addition, when a particular experiment results in the creation of a microorganism that is more dangerous to humans (more transmissible, more virulent, etc.), doubts might arise about whether the benefits of publication outweigh the risks. On the one hand, it might be argued that the mass communication of information on how a pathogen can become (and be made)

184   Christian Enemark more dangerous could enable and encourage the use of that information for a harmful purpose (such as a biological attack). On the other hand, making such findings widely available to other scientists might vitally assist the development of new or improved measures for controlling the relevant infectious disease. To the extent that sharing research findings with other scientists would be beneficial to public health, there is a technology-transfer imperative. But if there are risks associated with such sharing, a government might also act upon a perceived non-proliferation imperative to ­prevent this. The dilemma is well illustrated by the controversy surrounding the publication in 2012 of certain findings from research into the potential of H5N1 avian influenza (bird flu) to become more transmissible (Herfst et al. 2012). At the time of writing, there had been 860 confirmed human cases of H5N1 avian influenza in sixteen countries since 2003, including 454 deaths (a global average case-fatality rate of around 53 percent) (World Health Organization 2017). The continued circulation of H5N1 in poultry, and occasional infections of humans, has enabled ongoing viral evolution, and a key question for scientists has been whether this could eventually lead to the emergence among the human population of a virus with pandemic potential. Such a virus would be able to spread through the air between humans, and it would present a serious danger to public health globally, so some influenza researchers have been interested to discover which genetic mutations might allow H5N1 to do this. Ron Fouchier at the Erasmus Medical Centre (EMC) in Rotterdam, the Netherlands, was one of many scientists funded by the US National Institutes of Health to conduct experiments to investigate how H5N1 might evolve to acquire the ability to spread from person to person (Maher 2012, 432). In September 2011 Fouchier announced a breakthrough: using genetic engineering techniques, he and his research team had succeeded in causing the mutation of H5N1 into a form directly transmissible (through the air) between animals (Specter 2011). A ferret’s respiratory system closely resembles that of a human, and ferret-to-ferret transmission of influenza virus is generally assumed to demonstrate human-to-human transmissibility. Thus it seemed that a new and presumably pandemic virus had emerged not through natural evolutionary processes, but rather as a result of human experimentation. A written account of this discovery (including a description of how it was achieved) was made ready for submission to the highly respected US-based journal Science. Soon afterward, however, the Dutch government took an extraordinary action, requiring Fouchier to apply for and be granted permission to ‘export’ his team’s research findings beyond the European Union (EU) (Enserink 2012a). The legal basis for this intervention was EU Council Regulation 428/2009, which provides a framework for EU states to control exports of dual-use technology to non-EU states (European Union 2009). On April 27, 2012, the Dutch minister for agriculture and foreign trade announced his decision to allow the export of H5N1 technology to the editor of Science in this instance, stating that he had ‘weighed all of the benefits and risks of publication of the avian influenza research’ (Enserink 2012b). It is not clear exactly how the Dutch government arrived at and justified its decision. Did it do the right thing in allowing publication to

Biosecurity and the Risk to Global Health   185 proceed? Or should it instead have withheld an export permit and effectively censored Fouchier’s research findings? From a global health perspective, censorship might have been a beneficial move, insofar as it would have reduced the likelihood of Fouchier’s H5N1 experiment technique being applied by other scientists. Even if it was sufficiently safe for Fouchier and his colleagues to conduct their experiment inside the EMC in Rotterdam, the same work done (using a published methodology) in less well-managed laboratories elsewhere in the world might carry a greater risk of unintentional release of the mutated H5N1 virus. According to one estimate, the likelihood of a scientist somewhere being infected accidentally approaches 20 percent over a ten-year period (Lipsitch and Galvani 2014). Although Fouchier has insisted that ‘scientific research has never triggered a virus pandemic’ (Sample 2014), accidental infections involving the contagious severe acute respiratory syndrome (SARS) virus have gone undetected before (Murphy 2004; Yardley and Altman 2004). In addition, there is a risk that publishing a technique for producing a more dangerous version of H5N1 increases the likelihood of such technology being applied for a harmful purpose. The justification for censorship, then, might be, as Michael Osterholm has put it: ‘We don’t want to give bad guys a road map on how to make bad bugs really bad’ (Enserink 2011). On the other hand, if Fouchier’s H5N1 research findings had been censored, this could have been bad for global health for at least two reasons. First, censorship might have inhibited the ability of scientists (as readers of Science) to use a new discovery to better prepare for a pandemic. Several influenza virologists have emphasized the importance of information sharing for disease surveillance and vaccine-testing purposes (Osterhaus 2012; Palese and Wang 2012), and Fouchier’s core argument at the time was: We have to be prepared for such viruses to emerge in the wild. If we would detect these viruses out in the field, then we could go out to outbreak areas and try to eradicate the virus and prevent a pandemic from happening. If that would fail, then we would still be in a good position to, ahead of that pandemic, evaluate our vaccines and anti-viral drugs and therefore gain months of time if a pandemic would hit and therefore we would be able to handle it better.  (Fowler 2012)

A second reason that censorship might have been bad for global health is that concealment of information by one government can sometimes undermine international trust and cooperation. To the extent that preventing publication of Fouchier’s H5N1 findings would have limited access to potential public health benefits, the governments of developing countries in particular could have characterized this as contrary to the spirit of the 2011 Pandemic Influenza Preparedness Framework [PIPF] for the Sharing of Influenza Viruses and Access to Vaccines and Other Benefits (World Health Organization 2011b). This is an international agreement to share influenza virus samples and related information, and it critically relies on confidence that low-income countries (from which most H5N1 samples are sourced) will benefit from influenza research carried out in high-income countries. However, as the next section shows, such confidence can be undermined

186   Christian Enemark by perceptions that useful (albeit dual-use) technology and associated benefits are being deliberately withheld. The consequence thereof might be a downgrading of international cooperation on disease surveillance and influenza vaccine development, to the overall detriment of global health.

Biosecurity as Global Health Security: Prioritizing Risks and Responses Beyond biodefense and censorship carried out by governments individually, bi­o­se­cur­ity can also be a cooperative practice engaged in by multiple governments for the sake of populations that are collectively vulnerable to infectious diseases. Here too, difficulties can arise when priority status for a narrow range of disease risks (including the risk of biological attacks) is institutionalized by international health-governance arrangements for ‘global health security’. The challenge is to achieve extra protection for populations worldwide against prioritized disease risks without thereby neglecting other serious health burdens and health system problems in particular parts of the world. At the heart of this challenge is the tension between prioritization policies that promise to satisfy the greatest quantum of human need and those that are most likely to be politically feasible. David Stuckler and Martin McKee (2008) have observed that policymakers use different metaphors for global health, each of which results in the term meaning something other than the perfect health and complete well-being of all people everywhere. In accordance with the metaphor of ‘global health as public health’, for example, attention and resources are directed toward ‘decreas[ing] the worldwide burden of disease, with priority given to those risk factors and diseases that make the greatest contribution to this burden’ (96). This may be contrasted with the ‘global health as security’ metaphor, according to which health policy seeks to ‘protect one’s own [national] population, focusing mainly on communicable diseases that threaten this population’ (Stuckler and McKee 2008, 96). Emphasizing some infectious disease risks in pursuit of an agenda of global health security seems more likely to attract political and financial commitments from wealthy governments that are fearful of those diseases. However, such an arrangement could generate less public health benefit throughout the world than would one whose broader humanitarian rationale might be politically more difficult to support over the long term. In 2007 a World Health Organization (WHO) report defined ‘global public health security’ as ‘the activities required, both proactive and reactive, to minimize vulnerability to acute public health events that endanger the collective health of populations living across geographical regions and international boundaries’ (5). This definition immediately brings to mind outbreaks of diseases that are both deadly and fast spreading, like SARS and pandemic influenza. The implication of such framing is that problems of a non-‘acute’ nature are excluded from the agenda of global health security, even though the sum of such problems accounts for the greater part of health need throughout the

Biosecurity and the Risk to Global Health   187 world. For this reason, the institutionalized privileging of certain disease risks with conferred security status has been much criticized. In academic literature on the linking of health and security, a common complaint is that high-profile infectious diseases receive too much attention and that other health burdens (as reflected in morbidity and mortality statistics) are neglected. For example, Colleen O’Manique (2012, 167) has claimed that ‘[t]oday’s health and security agenda ignores . . . the boring, persistent, communicable and non-communicable diseases that in fact kill more people annually worldwide than high-profile diseases’. Simon Rushton (2011,: 780) has observed that global health security is in practice focused on ‘the protection of the West from threats emanating from the developing world’. And Debra DeLaet (2015, 342) has argued that placing diseases on security agendas is driven by ‘the political interests, strategic ­calculations, and influence of key actors in global health rather than . . . an objective assessment of where the most critical health needs exist’. The suggestion seems to be that more lives would be saved, and a greater quantum of health need fulfilled, if political attention were diverted away from diseases deemed to be of security concern and toward those health risks that are presently ‘the big killers’. One argument against this is that it is not enough to assemble health statistics demonstrating the actual burden of various disease risks and at any given moment contrast this with the non-occurrence of, say, an Ebola outbreak. This is because any priority-setting based solely on that assessment would fail to account for the possibility that the future might differ from the present. From the perspective of governments in developing countries, preparing for future ‘acute public health events’ (World Health Organization 2007, 5) might indeed appear, in the present, to entail the relative neglect of serious health burdens of an ongoing nature. However, poorer populations are generally more vulnerable to the effects of transnational epidemics when they eventually occur. Thus, even if the level of concern in developed countries about the spread of deadly infectious diseases seems excessive at times, it could be argued that governments in the developing world have a long-term interest in playing along. The agenda of global health security, institutionalized through the revised International Health Regulations (IHRs) of 2005, emphasizes local and global surveillance to detect deadly and contagious infectious disease outbreaks, and it calls for rapid responses to any ‘public health emergency of international concern’ (World Health Organization 2008). The IHRs place states under a legal obligation to report these types of outbreaks to WHO within twenty-four hours and to maintain their own core capacities for disease surveillance and rapid response. The idea is that with highly sensitive and well-connected surveillance systems in place, disease outbreaks will be detected and contained rapidly wherever in the world they occur. Of particular concern in this regard is the need to respond quickly to an emergent influenza pandemic which, if severe, could cause illness and death on a large scale, over a wide area, in a short space of time. Under the IHRs, the emergence of a new subtype of human influenza is automatically notifiable to WHO, which a decade ago described pandemic influenza as ‘the most feared security threat’ (World Health Organization 2007, 45).

188   Christian Enemark The principal benefit to be derived from global surveillance of influenza viruses is an early warning to all governments of the emergence, anywhere in the world, of a virus with pandemic properties. Such a warning of the commencement of human-to-human viral transmission is valuable because it supposedly allows everyone more time to, if possible, organize and implement a response. However, the value of a warning is potentially diminished by the continued inability of many countries to secure an adequate supply of pandemic influenza vaccines. A fundamental and persistent problem is that the total amount of influenza vaccine that can be produced annually is far from enough to protect everyone everywhere. The availability of a pandemic vaccine is not truly global, despite pandemic influenza having acquired priority status as a disease that poses a global health security risk. Therefore, only the wealthiest of countries, whose governments have pre-ordered doses of vaccine, are able to take full advantage of global influenza surveillance as a biosecurity practice. In mid-2009, for example, the United States had already ordered 40 million doses of vaccine against the pandemic H1N1 swine flu virus; the United Kingdom had ordered 90 million and France 50 million (Hayden 2009). Six months into that pandemic, only 534 million doses were available worldwide, and after one year there were 1.3 billion (Stöhr 2014). And so for the duration of the pandemic, a large majority of the world’s population (including many in countries with high incidence of infection) remained unprotected by vaccination. That swine flu pandemic turned out to be a mild one, but concerns about vaccine availability had been raised earlier by the governments of some developing countries fearful of the pandemic potential of H5N1 bird flu. In January 2007 the Indonesian government drew attention to its concerns by abruptly withholding samples of H5N1 virus from the WHO Global Influenza Surveillance Network. At that time Indonesia was continuing to experience many more cases of human H5N1 infection than any other country. Therefore Indonesia was a vital source of information on that influenza virus’s properties and whether it might be mutating into a pandemic form. Indonesia’s health minister, Siti Supari, used this fact to apply political pressure to further her country’s health interests. At a meeting with WHO officials in March 2007, she sought assurances that Indonesia would receive vaccines if a pandemic occurred, and she described the global vaccine supply scheme then in place as ‘more dangerous than the threat of an H5N1 pandemic itself ’ (Normile 2007). Assistant director-general David Heymann of WHO accused Indonesia of ‘putting the public health security of the whole world at risk’ by not sharing influenza virus surveillance data (Roos 2007). However, what Indonesia was essentially claiming was that poorer countries were already experiencing a high degree of health insecurity, and that cooperation with influenza researchers worldwide seemed pointless if those countries were unable to benefit from the vaccines that result from that cooperation. This claim thus presented a fundamental challenge to the practice of biosecurity qua global health security; achieving protection against selected infectious disease risks would only happen if there was international cooperation on disease surveillance. In formal recognition of the concern represented by Indonesia’s drastic action, four years later the World Health Assembly adopted the Pandemic Influenza Preparedness

Biosecurity and the Risk to Global Health   189 Framework (PIPF), which includes acknowledgements that ‘the benefits arising from the sharing of H5N1 and other influenza viruses with human pandemic potential should be shared’, and that ‘global influenza vaccine production capacity remains insufficient to  meet anticipated need in a pandemic’ (World Health Organization 2011a, 3–4). Nevertheless, the PIPF is legally non-binding—offering merely an encouragement to act—in contrast to the IHRs, which institutionalize the agenda of global health security. For example, the PIPF provides that ‘[WHO] Member States should urge vaccine manufacturers to set aside a portion of each production cycle of pandemic influenza vaccine for use by developing countries’ (World Health Organization 2011a, 20; emphasis added). Therefore, despite increasing the degree of political attention given to the issue of global pandemic influenza vaccine supplies, the PIPF could be characterized as a weak instrument that diverts this issue to the sidelines of the global health security agenda. If it is, and if the governments of some countries perceive a continuing gap between disease surveillance expectations and public health benefits, the potential for another virus-sharing dispute remains as a challenge to this form of biosecurity practice.

Biosecurity as Border Security: Transnational Contagion and Travel Restrictions The previous section discussed an international-level approach to biosecurity that is (or ought to be) inclusive and cooperative. This can be contrasted with the exclusionary and potentially divisive issue of border-based biosecurity. And yet it is also possible that the global health security agenda and restrictions on international travel (for purposes of disease control) are two sides of the same biosecurity coin. It is worth recalling that ‘global health’, as a discipline of medical science, is the sociotechnical descendent of what was previously called ‘imperial’ or ‘tropical’ medicine (Pinto et al. 2013, 12). The latter label alluded to security in the sense that in Europe in the nineteenth century, referring to parts of the world as ‘the tropics’ was ‘a way for imperial powers to define something culturally alien to, environmentally distinct from, and even threatening to Europe and other temperate regions’ (Birn 2012, 43). In accordance with this view, Scott Watson (2011, 163) has observed that the discourse and practice of ‘tropical’ medicine effectively ‘defined large portions of the earth as zones of danger for Europeans’. Between zones of danger and zones of safety, there is notionally a dividing line (border) that can be drawn and then policed as a way of protecting the health of a population on one side of the line from exposure to the diseased bodies of populations on the other side. Borders between states have long been sites of exclusionary modes of security practice. For governments confronting risks of many kinds, there is a strong and understandable temptation to think first about the territories for which they are responsible. When it

190   Christian Enemark comes to infectious diseases, and because human bodies can harbor disease-causing microorganisms, resisting a deadly and fearsome contagion can sometimes seem to require keeping people out. Border-based, migration-related biosecurity measures can thus serve a useful domestic political purpose in assuaging the anxiety of populations inside a given territory. However, preventing inward (and outward) travel is a measure that potentially does more harm than good, especially if an effective response to a disease outbreak is critically dependent on the free flow of people across international borders. A key principle since the international health-governance arrangements of the nineteenth century, which is repeated in the contemporary IHRs, is that states responding to the spread of disease must ‘avoid unnecessary interference with international traffic and trade’ (World Health Organization 2008, 10). The rationale for this is that excessively severe restrictions on cross-border travel can exacerbate rather than mitigate the adverse impact of a transnational disease outbreak. Moreover, in today’s highly interconnected world, in which microorganisms are as mobile as their human hosts, it is widely acknowledged that the policing of borders to prevent microbial incursions is often futile. Even so, circumstances may arise in which pharmaceutical resources (antibiotics, vaccines, etc.) are unavailable or insufficient. In these cases, a conscientious government might decide that there is no alternative but to adopt the centuries-old, non-pharmaceutical approach of containing contagion by limiting human movement and interaction (‘social distancing’). This was the case when, in 2014, the governments of Guinea, Liberia, and Sierra Leone confronted the largest-ever outbreak of Ebola, a disease that could not at the time be prevented or treated by any drug. The governments of some other countries, within and beyond West Africa, responded by unilaterally banning travel to and from the outbreak zone, hoping that extreme exclusion would prevent further contagion. This biosecurity practice, however, turned out to be counterproductive to defeating the Ebola outbreak. The Ebola virus does not transmit easily, so it is relatively easy to contain using basic infection-control measures. Therefore, in the absence of a safe and effective vaccine or therapeutic drug, the best approach to Ebola relief in West Africa was to insert a large number of capable, adequately supplied medical personnel into the situation to treat illness and prevent infection. To that end, in late July 2014 WHO director-general Margaret Chan announced a $US100 million plan to send more medical experts and supplies to the region (Nossiter and Grady 2014). Such an approach was stymied, however, by unilateral decisions by some governments to restrict or prohibit travel to and from the worst-affected countries. On August 8, 2014, when WHO declared the Ebola outbreak to be a ‘public health emergency of international concern’, its advice to all states was: ‘There should be no general ban on international travel’ (World Health Organization 2014a). By this time, however, a number of countries were attempting to establish international border-based obstacles to the spread of Ebola. Nigeria, Kenya, Ivory Coast, and Senegal banned all travel to and from Guinea, Liberia, and Sierra Leone (Anonymous 2014a; Anonymous 2014b; AFP 2014). Air France suspended flights to Sierra Leone on the recommendation

Biosecurity and the Risk to Global Health   191 of the French government (Wall 2014), and the South African government announced that non-citizens arriving from Ebola-affected areas of West Africa would not be allowed into South Africa (Anonymous 2014c). The reasoning behind imposing travel bans appeared to be that if some people traveling from West Africa might be carrying the Ebola virus, preventing inward travel by all such people would reduce the Ebola importation risk to zero. However, there was no scientific basis for adopting this extremely risk-averse approach, and this is why WHO repeatedly advised against travel bans (World Health Organization 2014b). When they were implemented anyway, such bans amounted to interference with international traffic that was not only unnecessary but also counterproductive. Travel restrictions made it more difficult to insert medical personnel and supplies into Ebola-affected countries, increasing the risk that local people would try to leave those countries in search of safety and/or treatment. In turn, this increased the risk of the disease spreading to other countries ill-equipped to cope with Ebola (Nuzzo et al. 2014, 307). By the end of August 2014, the presidents of Guinea, Liberia, and Sierra Leone were pleading for international travel bans to be lifted. In a letter to the United Nations (UN) secretary-general, the three presidents complained that the bans would end up aggravating the adverse economic effect of the Ebola outbreak and stifle attempts to control it (United Nations Security Council 2014a). The response by the UN Security Council on September 18, 2014, was to pass Resolution 2177, in which it expressed concern about ‘the detrimental effect of the isolation of the affected countries as a result of trade and travel restrictions’ (United Nations Security Council 2014b). Accordingly, the Security Council called on all states ‘to lift general travel and border restrictions’ and ‘to facilitate the delivery of assistance, including qualified, specialized and trained personnel and supplies, in response to the Ebola outbreak to the affected countries’ (United Nations Security Council 2014b). For the sake of public health within and beyond West Africa, the Security Council had moved to counteract the effect of a counterproductive, border-based biosecurity practice.

Conclusion Deadly infectious disease outbreaks are a great and growing concern for governments worldwide, but particular processes of addressing disease risks are potentially bad for global health. This potential derives from various biosecurity practices that could, paradoxically, increase the risk of disease outbreaks, prevent the use of technology for life-saving purposes, neglect ongoing health system problems, or inhibit the effective containment of transnational contagion. When biosecurity is pursued in the form of biodefense, there is potential for some activities carried out for threat assessment purposes to be construed as offensive in nature. If uncertainty about one state’s experimentation with biological dispersal systems prompts other states to seek a similar capability, the result could be a dangerous spiral of suspicion, proliferation, and a greater overall risk of

192   Christian Enemark biological attacks. When biosecurity means information security, a decision to prevent the publication of pathogen research findings might reduce the risk of technology being used for a hostile purpose. However, censorship might also inhibit the exploitation of a scientific discovery for the betterment of public health. Moreover, if security-based restrictions on communication of research data are perceived as a failure to share technology with countries that need it, this could jeopardize the international cooperation necessary for research-based disease surveillance. Detecting and controlling outbreaks of deadly and contagious diseases are the primary goals when biosecurity involves pursuing a global health security agenda in cooperation with other governments. The political challenge here, though, is to ensure that the task of alleviating ongoing health system problems in the developing world, such as inadequate access to pandemic influenza vaccines, is not neglected. In circumstances in which vaccines and other pharmaceutical resources are unavailable, some governments confronting the international spread of disease will be tempted to equate biosecurity with border security. Such an approach was taken to the extreme when Ebola struck West Africa in 2014, and it may have seemed at first to be better than allowing freedom of international movement to continue in the face of contagion. But this form of biosecurity practice is wasteful if it is unnecessary, and it is harmful to global health if it inhibits a cooperative international response.

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194   Christian Enemark Pinto, A. D., A.-E. Birn, and R. E. G. Upshur. 2013. ‘The Context of Global Health Ethics.’ In An Introduction to Global Health Ethics, edited by A. D. Pinto and R. E. G. Upshur, 3–15. New York: Routledge. Roos, R. 2007. ‘WHO: Indonesia’s Withholding of Viruses Endangers World.’ Center for Infectious Disease Research and Policy, University of Minnesota, August 7. http://www. cidrap.umn.edu/news-perspective/2007/08/who-indonesias-withholding-viruses -endangers-world. Rushton, S. 2011. ‘Global Health Security: Security for Whom? Security from What?’ Political Studies 59 (4): 779–796. Sample, I. 2014. ‘Virus Experiments Risk Unleashing Global Pandemic, Study Warns.’ The Guardian, May 21. http://www.theguardian.com/world/2014/may/20/virus-experiments -risk-global-pandemic. Specter, M. 2011. ‘The Trouble with Scientific Secrets.’ New Yorker, December 22. http://www .newyorker.com/news/news-desk/the-trouble-with-scientific-secrets. Stöhr, K. 2014. ‘Ill Prepared for a Pandemic.’ Nature 507 (7490): S20–S21. Stuckler, D., and M. McKee. 2008. ‘Five Metaphors about Global-Health Policy.’ The Lancet 372 (9633): 95–97. United Nations Security Council. 2014a. Letter dated 15 September 2014 from the SecretaryGeneral addressed to the President of the Security Council. S/2014/669, September 15. New York: United Nations. United Nations Security Council. 2014b. Resolution 2177 (2014). S/RES/2177, September 18. New York: United Nations. United States of America. 2016. Confidence Building Measure Return Covering 2015: Convention on the Prohibition of the Development, Production and Stockpiling of Bacteriological (Biological) and Toxin Weapons and on Their Destruction, Submitted to the United Nations on April 15. United Nations Office at Geneva. http://www.unog. ch/80256EDD006B8954/(httpAssets)/7047C6621AEBD1E2C1257F9400593E1D/$file /BWC_CBM_2016_United+States.pdf. US Army. 2012. ‘Capabilities Report 2012, West Desert Test Center.’ Dugway Proving Ground Business Development Branch. http://www.dugway.army.mil/Documents/2012 _Capabilities_Report.pdf. US Department of Defense. 1998. Militarily Critical Technologies List (MCTL), Part II, Weapons of Mass Destruction Technologies. Washington, DC: Office of the Under Secretary of Defense for Acquisition and Technology. https://fas.org/irp/threat/mctl98-2/mctl98-2.pdf. Wall, R. 2014. ‘Air France Suspends Flights to Freetown, Sierra Leone Over Ebola Outbreak.’ Wall Street Journal, August 27. http://www.wsj.com/articles/air-france-suspends-flights-to -freetown-sierra-leone-over-ebola-outbreak-1409150478. Watson, S. 2011. ‘Back Home, Safe and Sound: The Public and Private Production of Insecurity’. International Political Sociology 5 (2): 160–177. World Health Organization. 2007. A Safer Future: Global Public Health Security in the 21st Century. Geneva: World Health Organization. World Health Organization. 2008. International Health Regulations (2005). 2nd ed. Geneva: World Health Organization. World Health Organization. 2011a. Pandemic Influenza Preparedness Framework for the Sharing of Influenza Viruses and Access to Vaccines and Other Benefits. Geneva: World Health Organization.

Biosecurity and the Risk to Global Health   195 World Health Organization. 2011b. ‘WHO Concerned That New H5N1 Influenza Research Could Undermine the 2011 Pandemic Influenza Preparedness Framework.’ December 30. www.who.int/mediacentre/news/statements/2011/pip_framework_20111229/en/. World Health Organization. 2014a. ‘Statement on the 1st Meeting of the IHR Emergency Committee on the 2014 Ebola Outbreak in West Africa.’ August 8. http://www.who.int /mediacentre/news/statements/2014/ebola-20140808/en/. World Health Organization. 2014b. ‘Statement on Travel and Transport in Relation to Ebola Virus Disease Outbreak.’ August 18. http://www.who.int/mediacentre/news/statements/ 2014/ebola-travel-trasport/en/. World Health Organization. 2017. ‘Cumulative Number of Confirmed Human Cases of Avian Influenza A(H5N1) Reported to WHO.’ October 30. http://www.who.int/influenza /human_animal_interface/H5N1_cumulative_table_archives/en/. Yardley, J., and L. K. Altman. 2004. ‘China Is Scrambling to Curb SARS Cases after a Death.’ New York Times, April 24, 4.

chapter 11

Milita ry Assista nce du r i ng H e a lth Em ergencies Adam Kamradt-Scott and Frank Smith

Military forces have a long history of involvement in global health. For decades, and in some cases centuries, military forces have been engaged in activities ranging from eliminating mosquito breeding grounds (reducing the spread of malaria and yellow fever), to research and development of new treatments (contributing to therapies for cholera and Ebola, among other infectious diseases), to providing medical care in war zones and post-conflict environments. In recent years militaries have also addressed health through their participation in humanitarian assistance and disaster relief (HADR). Defense budgets have been bolstered, new military-to-military and civil-military agreements have been developed, and military personnel have even been encouraged to embrace the notion of ‘health as a bridge for peace’ and the provision of healthcare as a strategy to help them ‘win hearts and minds’. The potential for increased military involvement in health-related activities has led to what some critics describe as the ‘militarization’ of global health (Loyd 2009; Ingram 2005). Real or imagined, this perceived trend has been met with fierce resistance. Some medical professionals, public health advocates, and academics decry the risks of the military co-opting public health activities, distorting health priorities, and directly or indirectly threatening human rights and humanitarian workers (Noji 2005; Elbe 2006; Feldbaum et al. 2006). Some security professionals are sceptical as well, arguing that health issues ‘are not really our core business’ (Bernard 2013, 158). In short, the military’s role in emergencies and other health-related activities is controversial. This chapter examines the politics of using the military to provide health-related services during ‘natural’ disasters, as well as in complex emergencies that involve armed

198   Adam Kamradt-Scott and Frank Smith conflict. To illustrate the challenges and issues at stake, we use four prominent case studies: the deployment of Brazil’s military to help contain the spread of Zika in 2016, the international military response to the West African Ebola outbreak in 2014, the role of Pakistan’s military in the Global Polio Eradication Initiative, and the use of ‘tailgate medicine’ by coalition forces in Afghanistan and Iraq. In each case, we examine the criticisms of military involvement that have emerged, particularly among humanitarian and non-governmental organizations (NGOs), and the limited evidence of both success and failure.

Background Historians have long been aware of the devastating impact that poor health and disease outbreaks can have on military readiness and operations. Thucydides, for example, famously documented the damage wrought by an unknown plague on the people of Athens during the Peloponnesian War. Ever since, military historians have paid attention to the adverse impacts of disease, including the collapse of Alexander the Great’s conquest after he died from malaria (Cunha 2004), the decimation of indigenous populations by smallpox during the European conquest of the Americas (Diamond 1999), and the widespread death of soldiers from dysentery during the Napoleonic Wars (Cook 2001). Militaries have also paid attention to preventing disease through sanitation, treatment, research and development, and the formation of dedicated military medical services (Atenstaedt 2010). During the American Revolution, for instance, General George Washington ordered the Continental Army inoculated against the ravages of smallpox, which “must surely rank among his most important decisions of the war” (Fenn 2001, 134). Similarly, penicillin was first mass produced by the United States in preparation for the invasion of Normandy during World War II (Smith 2014a). Historically, the primary mission of military medical services was to treat combatants injured during fighting. Over time, however, such assistance has been interpreted more broadly, and it is now included as a standard component of stability and reconstruction operations, as well as HADR (Neuhaus 2008; Gordon 2011) and even health or science diplomacy (Smith 2014b). Offering this assistance has in turn helped militaries themselves in at least two ways. First, in strengthening force protection, armed forces have benefited from improved health both at home and when deployed abroad (Gibson 2013; Ingham 2014). Second, military medical services and scientific exchange programmes have created opportunities to build goodwill and improve military-to-military relations abroad (Engstrom 2013). Though the fact is sometimes unacknowledged, the military has also helped advance public health and medicine at large. For instance, US military research on vaccines for yellow fever helped pioneer the practice of informed consent, which ­subsequently became a standard requirement in clinical interventions (McManus

Military Assistance during Health Emergencies   199 et al. 2005; Artenstein et al. 2005). In addition, military research and development has contributed to numerous therapies and drugs for cholera, Q fever, plague, typhus, and tularemia, among other diseases; increased understanding of the pathogenesis and transmissibility of anthrax, leptosporosis, dengue, and viral hemorrhagic fevers (Christopher et al. 2005; Endy et al. 2005; Woodward 1981); and improved treatment for blood loss and traumatic injuries. Even the response to combat casualties helped inform what is now the common process of systematically assessing the injured— referred to as ‘triage’—to determine priorities for treating multiple patients with limited resources (Iverson and Moskop 2007). This is certainly not to say that the benefits to public health outweigh the overwhelming harm caused by war, or that the intentions behind military medicine are benign or altruistic. For example, the rise of tropical medicine in the 1800s is now understood to have served as a ‘tool of Empire’, promoting European dominance over colonial territories and their people (Curtin 1998; Vaughan 1991). During World War II, the US military argued that improving civilian health through increased investment in domestic healthcare was strategically important—not for humane reasons, but to support the broader war effort (Magee 1940). The impetus behind military involvement in health has often been organizational or national self-interest. Crucially, this self-interest—coupled with suspicion about ulterior motives—can cause unease and in some cases outright opposition to military involvement in health among some communities, public health advocates, and humanitarian groups. It is important to note that humanitarian organizations vary considerably in their approach towards civil-military cooperation. Some local NGOs will work with militaries to accomplish humanitarian objectives, viewing the armed forces as another source or supply of government services (Madiwale and Virk 2011). Other organizations, such as the International Committee of the Red Cross and Red Crescent (ICRC), will train military personnel in international humanitarian law but decline military assistance after natural disasters over concerns that accepting such help might undermine the organization’s reputation for neutrality (Bates 2014; Spoerri 2013). Médecins Sans Frontières (MSF) has traditionally opposed ‘military-humanitarianism’ in all forms—a position that may yet prove difficult to square with this organization’s explicit call for military intervention during the 2014–2015 Ebola outbreak in West Africa (Fox 2015; Kamradt-Scott et al. 2015). As Frerks et al. (2006) observe, such divergences in opinion demonstrate that the humanitarian community is far from homogenous and instead is comprised of ‘principled neutralitists’, ‘pragmatists’, ‘supporters’, and outright ‘opponents’ of military assistance. Opposition to military involvement in health activities is not without reason. In particular, aid organizations have objected to military-led health activities on the basis that they ‘blur’ the boundaries between military personnel and civilians, potentially increasing the risk that the latter will be viewed as legitimate targets by hostile combatants. Incidents such as the murder of five MSF staff members in Afghanistan after the US military became involved with delivering medical care to local communities seem to

200   Adam Kamradt-Scott and Frank Smith support these concerns (Katz and Wright 2004). Even inside the military, there is re­sist­ance to ‘military operations other than war’ (MOOTWs), as well as other activities such as medical research and development. Some military personnel are sceptical of supporting capabilities that differ from more conventional war-fighting activities, particularly when confronted with cuts to defense spending. Others—including some military medical professionals—have more nuanced concerns, arguing that interventions such as Medical Civic Action Programmes (MEDCAPs) may be too short-term to have lasting benefits for the populations they are intended to help, or that they may inadvertently undermine local health services (Gordon 2010, 2014). Although the conditions in which military medical assistance is appropriate have not been sufficiently specified, there are nonetheless a number of broad parameters for military involvement during health emergencies that have been enshrined in protocols such as the ‘Oslo Guidelines’ (Tatham and Rietjens 2016). One common premise is that the military should only ever be called upon as a ‘last resort’ (Anderson and Nevin 2016). Yet despite this stated policy preference, ambiguity remains about the actual meaning of ‘last resort’ (Tatham and Rietjens 2016). There are also potential opportunity costs—in lives lost—of waiting to cross this vague threshold. As a result, confusion persists over when it is legitimate or appropriate to engage military forces, and similarly, over what types of health activities—if any—they should undertake. However, at least two analytical distinctions can be drawn when surveying military involvement. The first is whether a given emergency is ‘natural’ or ‘complex’. Few humanitarian organizations would contest the idea that militaries can play an important role in the aftermath of a natural disaster. Most militaries would acknowledge the same. Indeed, since the end of the Cold War several militaries from high-income countries have assumed prominent roles in international disaster response and recovery. Among other examples, Russian military aircraft were used to transport humanitarian aid to China following the 2008 Sichuan earthquake (Licina 2012). Similarly, the US military airlifted humanitarian aid, healthcare workers, and patients after the 2010 earthquake in Pakistan and after the 2014 typhoon in the Philippines (Lum and Margesson 2014; Madiwale and Virk 2011). The US and Australian militaries also deployed personnel and assets to Indonesia following the 2004 tsunami (Byleveld et al. 2005). In each of these cases, domestic military personnel were already on the ground, and for many low- and middle-income countries, their militaries are the only national ‘emergency services’ that are available. Thus, in the context of natural emergencies, military medical assistance may even be described as ‘the backbone of disaster medical relief ’ (Liu et al. 2014, 33). A different set of circumstances arises when the environment is post-conflict, or, relatedly, a ‘complex emergency’ in which some form of fighting is ongoing. When armed forces have served previously as belligerents, or when the security environment is transitional, civil-military cooperation understandably becomes much more fraught. The risk to humanitarian workers may in turn increase if they are perceived to be associated with armed forces (Winslow 2002; Wilson 2009). In these circumstances, rather than overt cooperation, an alternative approach may be either ‘co-ordination’ between humanitarian organizations and military forces that operate independently but regularly

Military Assistance during Health Emergencies   201 liaise to prevent duplication of effort, or ‘co-existence’, whereby these organizations operate fully independently of each other and accept the potential costs of having little or no communication (Heaslip and Barber 2014). Along with natural versus complex emergencies, a second useful distinction is whether the military force(s) involved are foreign or domestic. As discussed later in this article, foreign military assistance (FMA) proved instrumental during the 2014–2015 Ebola outbreak in West Africa, particularly in terms of its positive psychological impact. But this was a rather unique set of circumstances, because the FMA enjoyed community support, due in part to a long period of post-conflict reconstruction and bilateral cooperation. That may not always be the case, particularly in locations where foreign military forces have previously fought. It is therefore plausible to expect that FMA can either benefit or detract from the response to complex emergencies, depending on the relationships and reputations of the militaries involved and the governments they represent. Similarly, civil-military health cooperation can be greatly influenced by the reputation of domestic military forces. Community perceptions of their own armed forces vary considerably. In countries where military forces have traditionally remained separate from civilian affairs, trust in military integrity is generally high (Gronke and Feaver 2001). But even where the military enjoys support, political and religious divisions can adversely impact public perceptions of this institution (Narli 2000). In other countries, military involvement or interference in domestic politics may also result in the armed forces enjoying community support (Sarigil 2009), particularly when civilian politicians are viewed as corrupt (Lugo and Searing 2014). Elsewhere, however, the military may be seen as no less corrupt than civilians (especially where there is limited oversight), which can fuel negative public opinion (Ungar 2013). Like other security services, the military is not exempt from domestic suspicion and outright distrust. As this overview suggests, civil-military cooperation in health and humanitarian contexts remains controversial, and military involvement in responses to emergencies is complicated. Still, militaries have been involved with global health for a long time, and expectations regarding their assistance during times of crisis may be growing. Therefore, in the remainder of this chapter we examine four situations in which militaries have been called upon to render medical assistance during emergencies: in Brazil, West Africa, and Pakistan, as well as during the wars in Afghanistan and Iraq. These case studies highlight important challenges and opportunities that may arise when armed forces provide medical assistance.

Brazil and Zika One example of military forces being deployed in a domestic context to address a ‘natural’ health emergency occurred in February 2016. The identification and discernible spread of the Zika virus in Brazil before the 2016 Olympics—to be held in Rio de Janeiro— gained extensive media coverage around the world. In response to rising concerns about

202   Adam Kamradt-Scott and Frank Smith the risk to athletes and visitors, the Brazilian government took the unprecedented step of deploying over 220,000 military personnel in a campaign to eliminate mosquito breeding environments, distribute educational pamphlets, and apply larvicides in the areas of immediate concern (Szklarz 2016). Some commentators suggested that using the armed forces in what was essentially a public health campaign reflected a broader narrative the government had been promoting of ‘Brazil as a responsible global leader’, with the deployment of military personnel (including former peacekeepers) exemplifying its commitment to humanitarian ideals (de Oliveira 2016). By comparison, others have argued that this deployment reflected chronic underinvestment in the Brazilian healthcare system, which was overstretched and thus unable to respond with a purely civilian public health intervention (Hennigan 2016). Either way, the decision to deploy the Brazilian military to fight Zika was a political and potentially high-risk strategy. The relationship between civilian authorities and the military in Brazil has a strained history, given military interference in Brazilian politics that culminated in a military coup in 1964 (Stepan 1971). Civil-military relations have improved since then, although financial crises, disputes over salary levels, and reductions in military personnel throughout the 1990s added to the tension (Sotomayer 2013). At the same time, Brazil increasingly used its military in non-war-fighting contexts, and during the 2000s the government launched a campaign to ‘redefine its global identity’ by committing to international peacekeeping missions (Sotomayer 2013, 55). Reportedly, its first goal was to modernize the army, since soldiers deployed on these missions would purportedly gain an appreciation for the rule of law and conflict prevention, and to ‘democratize’ the military mindset. This experience could thereby help the military meet its constitutional obligations, which include assisting in natural emergencies and combating violent threats to public safety (Cepik and Bertol 2016). A second goal was to demonstrate commitment to international peacekeeping missions and thus strengthen Brazil’s case for a permanent seat on the United Nations Security Council (Sotomayer 2013). Along with increased peacekeeping, Brazil also diversified the types of missions and personnel that it deployed, which over time included medical teams (Cavalcante 2010). After playing a small role in UNTAET in Timor Leste, Brazil significantly increased its commitment to assist the UN mission to Haiti, Mission des Nations Unies pour la stabil­ ization en Haïti (MINUSTAH), in 2004 (Kenkel 2010). According to Arturo Sotomayer (2013), however, the ‘pacification’ skills that the Brazilian military learned in Haiti were then reused in 2010 to clear slums in Rio de Janeiro (favelas) of drug traffickers and gangs. A similar strategy was employed again in 2014 in preparation for Brazil’s hosting of the World Cup (Sotomayer 2013, 88; Harig 2015). These domestic deployments were met with resistance, increasing the potential risks associated with the subsequent decision to deploy the military to help halt the spread of Zika. The military’s heavy-handedness in 2010 resulted in summary executions, martial law, and ‘tanks blasting through improvised roadblocks’ (Gaffney 2012, 75). Violence against the military escalated when the armed forces were used to pacify the Rio favelas again in 2014 (Watts 2014).

Military Assistance during Health Emergencies   203 When it came to Zika, public announcements stressed the non-violent, unarmed nature of the military’s involvement, using the slogan ‘strong arm, friendly hand’ (Lesser and Kitron 2016; Conners and Jelmayer 2016). In addition, military personnel were ordered to avoid a number of Rio favelas because of personal safety concerns (de Oliveira 2016). However, this meant there was less than comprehensive coverage of areas where the virus may have spread. Indeed, whereas it had initially been estimated that the military would investigate some three million households (Szklarz 2016), only one-third of these were reportedly surveyed (Castro 2016). As a result, some of the communities at greatest risk of exposure to Zika did not benefit from military assistance in the removal of still water catchments and the application of larvicides. Many military personnel were limited to distributing information pamphlets (de Oliveira 2016), a relatively trivial task that raises the question: Given the risks of deploying the military, combined with the limited assistance it was actually able to render, why was the military deployed in the first place? Militaries tend to be cohesive, hierarchical, and disciplined organizations. In functional militaries (some may be dysfunctional), cohesion is traditionally maintained through a common set of values and beliefs, an esprit de corps, with which service members are inculcated when they join, and which is regularly reinforced through emphasizing group loyalty, ritual, and routine. Militaries are also hierarchical organizations with centralized and relatively depersonalized command and control. Military personnel are required to respect their chain of command and follow orders irrespective of personal differences, as rank determines authority. Strict discipline is further enforced via a range of ideas, incentives, and penalties that promote compliance. Taken together, these attributes, which are intended to increase effectiveness in war, may enable a military to act with a common purpose that exceeds that of its civilian counterparts (Finer 2002). Moreover, the armed forces represent the ultimate form of state power. Their traditional function is to defend the homeland (Edmunds 2006), signaling their importance to the state, which in turn imbues military action with additional meaning and significance. As Jeff Hearn (2003, xi) summarizes, ‘military matters are urgent and powerful’. Consequently, using the military in response to Zika not only enabled Brazil to rapidly mobilize a regimented workforce, it also sent a strong signal to domestic and inter­ national audiences that the government was taking this outbreak seriously. Perhaps the military stood to gain as well from participating in this humanitarian initiative, since it offered an opportunity to repair public perceptions that may have been damaged during interventions in 2010 and 2014. Deployment of military personnel on the streets of Rio, notably accompanied by the president of Brazil, sent a strong message that the government and military were committed to working together to secure the country’s health and well-being. The military was not there to punish, but rather to help protect and support local communities. At the same time, military involvement provided a prominent show of force to the international community that Brazil was taking the Zika ‘threat’ to international visitors and athletes seriously before the 2016 Rio Olympics. Therefore, while the practical role of the military may have been limited in terms of time and function, there were notable benefits to be gained.

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Ebola and the International Response in West Africa To date, the single largest mobilization of military assets—in terms of personnel and hardware—solely to provide emergency health assistance was in response to the 2014 Ebola outbreak. In total, more than five thousand foreign military personnel from the United States, the United Kingdom, China, Canada, Germany, France, and the African Union were deployed to help the governments of Liberia, Sierra Leone, and Guinea eliminate this disease (Kamradt-Scott et al. 2015). In addition, domestic military forces in these three countries were also engaged in helping civilian authorities and preventing further Ebola-related morbidity and mortality (Kamradt-Scott et al. 2015). This deployment of military personnel has generally been hailed as a success, even to the point of suggesting that it was instrumental in containing this outbreak. The West African outbreak was traced back to Guinea in December 2013, having started in a village neighbouring Liberia and Sierra Leone, but it was only identified as an outbreak of Ebola Virus Disease in March 2014. The virus spread across West Africa (principally Guinea, Liberia, and Sierra Leone, with a small number of cases in Nigeria), most notably in major cities, where it inflicted considerable morbidity and mortality. According to official figures, more than 28,000 people became infected and over 11,300 died (WHO 2016), although it is generally accepted the actual number of cases may have been much higher. This outbreak was eventually contained and declared officially over in January 2016, but there have been a number of isolated cases of survivors subsequently infecting close contacts (otherwise described as ‘flare-ups’). Due to the increasingly high prevalence of Ebola patients in September 2014, MSF made the highly unusual move of requesting foreign military assistance in West Africa. As early as August 2014, however, US and Chinese military officials were already in affected countries undertaking their own assessments, providing technical expertise, and—in the case of China—rendering some medical care (Fan et al. 2015). By October 2014, advance military teams from several countries arrived in West Africa to establish their respective bases of operations. By December 2014, FMA had reached its peak across the region. The US and UK military forces were deployed to Liberia and Sierra Leone, respectively, reflecting their historical ties as well as post-conflict reconstruction and military cooperation (Nevin and Anderson 2016, Kamradt-Scott et al. 2015). Other military forces, such as China’s People’s Liberation Army (PLA), established operations across all three of the worst-affected countries (Taylor 2015). The most common roles performed by FMA during this outbreak were training local healthcare workers and building Ebola treatment units (ETUs). Beyond this, the functions and activities that each military performed varied considerably. For example, whereas the UK and Chinese militaries established medical units that were staffed by military physicians and nurses to care for suspected or confirmed Ebola patients, the US military was prohibited from offering medical care. The US military was also prohibited (as a matter of policy)

Military Assistance during Health Emergencies   205 from transporting individuals suspected of having contracted Ebola and even biological samples (Anderson and Nevin 2016; MSF 2015). By contrast, the German military medical team worked collaboratively alongside the German Red Cross in Liberia to provide medical care principally to non-Ebola patients, as other medical services had been interrupted or canceled (Kamradt-Scott et al. 2015). Domestic militaries also varied in their roles and levels of activity. Inside Liberia, the Armed Forces of Liberia (AFL) were initially engaged in enforcing law and order, as well as restricting travel between areas. Following the death of a teenage boy who was shot during a riot, the AFL assumed a less prominent role for the remainder of the outbreak. In Sierra Leone, not only did the armed forces assume a leading role in coordinating the national Ebola response, but military personnel were also deployed to help protect healthcare workers and burial teams, enforce quarantine, and restrict travel between affected areas. Moreover, whereas all foreign military personnel were unarmed, some domestic military forces were observed to carry weapons and reportedly engaged in sporadic violence in the exercise of their duties, such as quarantine. These actions understandably provoked controversy, particularly among members of local communities, who questioned why military personnel needed to carry arms if they were ‘fighting a disease’ (Kamradt-Scott et al. 2015). The models for civil-military cooperation employed in West Africa varied as well. Whereas the British military had been deployed ostensibly to support the UK Department for International Development (DfID), in practice the British effectively assumed control of the Sierra Leonean response in all but name, only handing control back to the national Ebola task force—which was overseen by domestic military personnel—in December 2014. By contrast, in Liberia the national response was coordinated by the Ministry of Health and Social Welfare. The US military was deployed to support Liberia through the US Agency for International Development (USAID), remaining at arm’s-length, with coordination via regular civilian-led meetings (Nyenswah et al. 2016; Kamradt-Scott et al. 2015). In further juxtaposition, PLA forces were present in these same countries, yet their personnel rarely attended civil-military coordination meetings. The variation between different military roles and levels of civil-military cooperation contributed to some confusion among humanitarian aid workers and recipient communities. MSF, for example, noted that its own capabilities were insufficient to address the outbreak, and it simply assumed that calling for military intervention would result in the rapid deployment of ‘biohazard containment’ capabilities and/or ‘biological warfare expertise’ (MSF 2015, 13). Instead, the majority of FMA was limited to ‘support, coordination and logistics’ (MSF 2015, 14). More important, local communities were also perplexed by differing standards, not only regarding the level and quality of clinical care provided by military forces, but also about whether and why domestic military personnel were armed (Kamradt-Scott et al. 2015). Although the general consensus was that civil-military cooperation worked well, concerns were raised about the slowness with which the militaries constructed ETUs (Nevin and Anderson 2016), the risk aversion displayed by some forces (e.g., refusing to transport infected patients), the lack of flexibility in mission parameters (e.g., the requirement to build ETUs to British building

206   Adam Kamradt-Scott and Frank Smith standards, which notably included snow loading), and the masculinized spaces for decision-making (Kamradt-Scott et al. 2015). When combined with the differences observed in FMA functions and activities, as well as the divergence in how the military forces approached civil-military cooperation, it is apparent that there remains a lack of consensus about the appropriate role of the military during health emergencies. That being said, FMA appears to have had a significant and positive psychological impact on civilian populations and organizations alike. As one UN official characterized the arrival of US military in Liberia, ‘Had the Americans simply driven from the airport through Monrovia to their base and not done another thing, the mission would have been a success. It was a massive demonstration of goodwill’ (Kamradt-Scott et al. 2015, 14). Similar sentiments were expressed by local community members in Sierra Leone regarding the arrival of British military personnel. Moreover, several NGO representatives acknowledged that the commitment of Western governments to deploy military forces changed their plans, which otherwise had been to cease operations and exit the affected countries (Kamradt-Scott et al. 2015). This suggests that FMA may have a wider impact beyond the immediate technical expertise and/or logistical capabilities provided by the militaries themselves.

Polio Vaccination in Pakistan Pakistan is one of two remaining countries where polio currently remains endemic. Routine immunization against poliovirus began in Pakistan in 1978. These efforts were expanded with the launch of the World Health Organization’s (WHO) Global Polio Eradication Initiative in 1988. But it was not until 1994 that Pakistan’s government implemented a systematic campaign that included regular surveillance, house-to-house visits, national immunization days, and ‘supplementary’ immunization initiatives during agreed upon ceasefires in conflict-affected areas (Hussain et al. 2016; Munir and Rehman 2016). The prospects for polio eradication in Pakistan remain fraught to this day, in large part due to ongoing security concerns. Between 1998 and 2012, polio eradication workers operated in Pakistan without significant interference or threat of harm. In 2012, however, the Taliban imposed a ban on polio vaccination in the Federally Administered Tribal Areas (FATA). This vaccination ban is widely believed to have been imposed because of revelations that the US Central Intelligence Agency (CIA) used a hepatitis B vaccination campaign to help locate and ultimately kill Osama bin Laden (Ahmed 2015). Following the ban, violent attacks against polio eradication workers escalated, in which more than eighty personnel were killed, and causing the campaign to be officially suspended throughout the FATA in 2014 (Hussain et al. 2016; Kakalia and Karrar 2016; Gill 2016). Attacks against people who had been vaccinated increased as well, with individuals who received the vaccine reportedly being subject to public beating, humiliation, and even abduction (Munir and Rehman 2016). In response to this violence, Pakistan initially deployed the police force

Military Assistance during Health Emergencies   207 to accompany the polio eradication workers. In total, more than fifty-five hundred police officers were assigned to provide security and protection to the vaccination teams as they went about their duties (Yusufzai 2014). However, attacks against healthcare workers did not abate, and some police units were negligent in their duties. Calls soon emerged among the public health community to replace the police with military personnel (Hussain et al. 2015). These requests were supported, notably, by WHO officials. The WHO assistant director-general for polio eradication, Dr Bruce Aylward, argued in 2014 that ‘the full assistance of the Pakistan military is needed to make sure that vaccination can be done safely, especially in the many, large conflict areas’ (Maurice 2014, 940). Despite this international support, the decision to deploy the Pakistani military to protect polio eradication efforts still proved controversial. The Pakistani military has been heavily engaged in fighting insurgents in areas resistant to polio vaccination, including the FATA. These counterinsurgency operations have disrupted or prevented access to the areas where vaccination coverage was already minimal or non-existent (Wassilak et al. 2014). This ongoing conflict has also displaced millions of people, contributing to the spread of the polio virus across Pakistan and abroad (Hussain et al. 2016). The risk of further spread subsequently prompted WHO to recommend travel restrictions, requiring all Pakistanis to produce a vaccination certificate prior to international travel (Ahmed 2015). In this context, having military personnel accompany polio vaccination teams could have increased controversy surrounding the eradication effort (Ahmed 2015). Using the Pakistani military to support polio eradication highlights many of the concerns traditionally associated with military involvement in health activities. On the one hand, the intention behind this military deployment is probably to protect the civilian vaccination teams and thereby advance the eradication campaign. Rather than provide medical care or treatment, the military has provided a service well within its conventional remit, namely physical security. As such, this case conforms to standard expectations for civil-military cooperation in complex emergencies. On the other hand, the fact that Pakistan’s military has been engaged in protracted fighting with insurgents (many of whom reside in areas where the vaccination campaign has been interrupted) may challenge or complicate the perceived neutrality of this public health initiative. For the polio vaccination teams, being seen to work closely with the military may alienate some of the communities that they are seeking to assist. As a result, the short-term gains achieved through increased protection for these teams may unintentionally undermine public trust and thus some longer-term public health goals and objectives. Whether these longer-term risks outweigh the potential near-term gains is an open question, however, rather than a forgone conclusion. It would be a mistake to assess the military means involved without considering possible health outcomes, such as the eradication of polio. The actual impact on healthcare workers is another critical question. Whether they benefit more from increased protection than they lose from associating with the military may be far more important to the people at greatest risk in Pakistan— either from polio itself or from the backlash against this vaccination campaign—than whether foreign advocates for public health and humanitarian aid resent or oppose

208   Adam Kamradt-Scott and Frank Smith military involvement. What has become apparent, however, is that the utilization of military personnel is in several respects currently outstripping any consensus on how and where they should be used in health-related activities. It is likely that assistance from the Pakistani military is more acceptable to local communities than if the armed forces were foreign (especially since a CIA operation fuelled the initial controversy in this case). It is easy to imagine, for example, that foreign military intervention could reinforce the conspiracy theory that polio vaccination is a plot by the West to sterilize and depopulate Muslim countries (Hussain et al. 2016). Here, as elsewhere, it is important to assess the involvement of foreign and domestic militaries in public health relative to alternative options, and this includes analyzing the impact or opportunity costs of avoiding military involvement altogether.

Tailgate Medicine in Iraq and Afghanistan ‘Tailgate medicine’, as the name implies, is medical care dispensed from the back of a truck or a similar temporary facility (McInnes and Rushton 2012; Lougee 2007). The US military in particular has a long history of providing this kind of temporary care through MEDCAPs. For example, these programmes were used to varying degrees during the 1950s in the Philippines, in the 1960s in Vietnam, and in the 2000s in Iraq and Afghanistan (Baker 2007). MEDCAPs have also been used during peacetime to provide medical care to rural and/or remote communities in low-income countries that would not otherwise have ready access to these services (Bouchat 2015). For instance, the hospital ships USNS Comfort and Mercy are often deployed for peacetime operations (Waller et al. 2011). Still, the temporary and ad hoc nature of this assistance remains the same. Tailgate medicine was a notable and common practice in the Afghanistan and Iraq Wars. In both countries, coalition forces—namely the Multi-National Force–Iraq (MNF–I) and the International Security Assistance Force (ISAF) in Afghanistan— engaged in MEDCAPs. These programmes were often part of stability or counterinsurgency operations designed to ‘win hearts and minds’, gather intelligence, and promote other military or political objectives (Malish, Scott, and Rasheed 2006; Baker 2007; Olsthoorn and Bollen 2013). In this respect, military medical personnel and the services they provided were intended to achieve some tactical, operational, or strategic benefit. While perhaps related, the health outcomes of local populations were implicitly of secondary importance. As Thompson (2008, 1) observed in Afghanistan, for instance, ‘Medical interventions are an important component of a diplomatic strategy to regain moral authority for U.S. actions, regain the trust of moderate Muslims, and deny terrorists and religious extremists unencumbered access to safe harbor in ungoverned spaces’. Similar motivations were behind MEDCAPs in Iraq, which appeared to provide ad hoc solutions to health emergencies in the absence of a more robust policy for rebuilding of the country (McInnes and Rushton 2014).

Military Assistance during Health Emergencies   209 It is not surprising that the temporary, impromptu, and intermittent nature of this assistance prompts considerable criticism, especially from within the public health and humanitarian aid communities (Rietjens and Bollen 2016). They are not alone; some military medical personnel have also discouraged this kind of assistance. For instance, according to one US Army physician, ‘[T]ailgate medicine, as commonly practiced by many well-meaning [MEDCAPs], is not an effective tool for commanders conducting counterinsurgency operations in the Iraqi theater of operations’ (Baker 2007, 67). Others have remarked that such programmes ‘do not win hearts and minds nor improve population health’ (Cameron 2011, 209), or that, although good alternatives may be lacking, ‘[i]t is important for medical planners to carefully consider all possible consequences before committing to medical civilian aid programmes’ (Bricknell and Nadin 2017, 5). Again, like all medical assistance, MEDCAPs are best assessed relative to feasible alternatives. On the one hand, they may be considered a better alternative than no healthcare at all. Yet it is also important to appreciate that short-term approaches stand to have unwelcome consequences, both for the local population and the military supplying the assistance. These include the inability to provide continuity of care, the difficulty of making reliable diagnoses, the lack of appropriate drugs and treatment regimes, the difficulty of providing equal access to care, the tendency to draw large crowds (thereby creating a potential target for opposition forces to attack), and the potentially negative impact on the long-term development of local healthcare providers and services (Bulstrode 2009; Gordon 2011). While the local population bears the brunt of these problems, the military’s overarching mission may also suffer from inadequate provision of medical assistance. As Bricknell (2014, 455) notes: Military medical activity undertaken for perceived short-term gains may undermine the military mission in the medium to longer term, particularly in counter-insurgency (COIN) operations, by reducing confidence among the indigenous population in their government’s ability to provide these essential services.

There are reputational risks as well, even in peacetime. It has been reported that poor performance on one US military medical mission in Trinidad resulted in such ‘a significant backlash’ that longer-term plans to help build local capacity had to be redesigned (Haims, Duber, and Chang 2014, 660). In peace and war, gross discrepancies between the medical care that a foreign military provides for itself and that rendered to the host nation and local civilians may also cause ethical and practical problems (Gross 2013). Still, these problems are not unique to military medical assistance. Humanitarian organizations make mistakes that undermine long-term goals, and they tend to reserve the best care for their own people (as was evident during the 2014–2015 Ebola outbreak). For better or worse, MEDCAPs are likely to remain part of the US military’s arsenal, and their recognized shortcomings provide ample ground for learning and improvement. One common recommendation is for more collaborative medical engagement, especially with local healthcare providers (Malish, Scott, and Rasheed 2006; Bricknell and Gadd 2007; Lesho, Jawad, and Hameed 2011). This may include educational support for local

210   Adam Kamradt-Scott and Frank Smith partners to help improve the sustainability of these medical interventions (Alderman, Christensen, and Crawford 2010). Similar arguments and evidence also support greater communication and collaboration among the military, international organizations, and NGOs (Pueschel 2010; Miles and Malone 2013). Improvement along these lines may in turn enhance the health outcomes associated with this kind of military medicine.

Conclusion Militaries have long been called upon to provide health-related assistance. The health emergencies that they may respond to can vary, and the identities and functions of the militaries involved can vary as well. While the history of military assistance is long and complex, this brief survey provides an analytical framework and comparative context to help understand the relationship between military forces and health emergencies in the past, present, and future. However, we still lack a robust framework to evaluate how and when militaries should be called upon to assist, including the types of activity it is reasonable to expect them to perform. As part of our contribution to developing such a framework, we suggest that it is useful to distinguish natural disasters and disease outbreaks from complex emergencies that include armed conflict. Foreign versus domestic military assistance is another critical distinction. Through case studies of Brazil’s fight against Zika, the outbreak of Ebola in West Africa, polio vaccination in Pakistan, and MEDCAPs in Iraq and Afghanistan, this chapter has considered some of the concerns and controversies that surround military health assistance. These include the ‘militarization’ of humanitarian assistance, the ‘blurring’ or confusion of humanitarian and military roles, short- versus long-term health objectives and outcomes, and the ever-present political interests involved in local and global public health. In addition, we have noted some of the ways that military assistance may have made positive contributions in each of these cases. While noting these contributions and concerns, we have sought to avoid the common tendency to draw stark moral or normative conclusions about the appropriateness of military assistance. Granted, we do suggest that the analysis of such assistance should consider the alternatives available, as well as the impact on those communities that stand to be most directly affected. Yet this kind of analysis is warranted given the significance—for better or worse—of military involvement. More research is also justified because, as in the past, it is likely that we will continue to witness military personnel being deployed during future emergencies and crises to render healthcare. Until this further work is undertaken, consensus on where and under what circumstances military assistance in health emergencies is appropriate will continue to elude us. While this may conceivably be welcomed by some, there are times when the participation of armed forces in an emergency can provide explicit benefits, particularly with regard to securing the operational environment. Moreover, where human lives are at stake, governments may be tempted to utilize whatever resources they have at their

Military Assistance during Health Emergencies   211 disposal. In such contexts, it is arguably better to have clear guidelines on where military assistance in a health emergency can be appropriately used. In the interim, important questions about the long-term versus short-term gains surrounding the ‘blurring’ of boundaries, public health benefits, and risks to healthcare workers need to be carefully weighed and evaluated to avoid unintended consequences.

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chapter 12

Gl oba l He a lth a n d I n ter nationa l Dev el opm en t Andrew Harmer and Jonathan Kennedy

In this chapter we explore the relationship between international development and global health. To do this, we first reflect on the meaning of development. One way of understanding development is that it implies something positive: human progress, the betterment of society, or simply good change (Chambers 1997). Although this definition is intuitively appealing, it is also problematic: What is good, against which and whose definition is good measured, and what is the best way to bring about good change? A more radical critique argues that development is a discourse used by ­powerful actors in the global North to exploit the poor and destroy the environment in the global South (Rist 2007). In this view, development is not about good change but a euphemism for the destruction of society and nature in the pursuit of wealth. Another way to understand development is to distinguish between two meanings (Thomas 2000; Brown and Hanlin 2013; Szirmai 2017). The first, immanent or unintentional development, denotes the ‘historical process of social change in which societies are transformed over long periods’ (Thomas 2000, 29). This approach tries to explain why some regions are so much more prosperous than others. It considers processes such as the ‘Great Transformation’ from pre-capitalist society to a capitalist market society (Polanyi 2001); the ‘Great Divergence’ (Pomeranz 2000) between Europe and its settler colonies and other parts of the world; and globalisation, the increasing worldwide interconnectedness of many aspects of life (Held et al. 1999). The second meaning, planned or intentional development, refers to the ‘deliberate policies and actions of development agencies’ (Thomas 2000, 29). It is concerned with the way in which g­ overnments, international organisations, and non-governmental organizations (NGOs) undertake relatively short-term projects in order to ­encourage development of various sorts (Szirmai 2017). The ostensible aim of planned or ­intentional development is to transfer the benefits of immanent development to the global South (Sachs 2005). In practise, however, it is

218   Andrew Harmer and Jonathan Kennedy widely argued that development  is motivated by flawed reasoning or economic and political self-interest (e.g., Easterly 2006; Rist 2007). The most recent focus of this form of development is the two UN initiatives, the millennium development goals (MDGs), which ran from 2000 to 2015, and the sustainable development goals (SDGs), which will frame member states’ development agendas and policies over the next decade and a half. Clearly, whether defined as a historical process or as a technical project, development has enormous implications for global health. Regarding the former, it is widely held that as countries become wealthier, they become healthier (Preston 1975; Pritchett and Summers 1996; Deaton 2003; see also Sparke in this volume). It is also axiomatic that socio-economic development results in the epidemiological transition, as infectious and parasitic diseases are replaced by congenital and degenerative diseases (Omran 2005). Conversely, high levels of disease can negatively impact a country’s ability to develop economically (World Bank 1980; Sachs and Malaney 2002). Health is a key aspect of planned or intentional development precisely because of the realisation that it is crucial to improving the lives and livelihoods of people in the global South. The World Health Organization (WHO) was founded in 1948 as the United Nations (UN) specialised agency for international health (Brown, Cueto, and Fee 2006; Cueto in this volume). Actors such as the World Bank, the Gates Foundation, and a variety of partnerships such as the Global Fund have played an increasingly important role in global health. The MDGs and the SDGs specifically refer to health objectives—for example, the third SDG is ‘Ensure healthy lives and promote well-being for all at all ages’—and other targets are related to the broader determinants of health (UN n.d.). This chapter is broken into two main sections. The first considers immanent or unintentional development and its relationship with global health. It demonstrates that socio-economic development over the last two centuries has resulted in massive inequalities between and within countries, as well as environmental destruction. These have significant implications for global health. The second section considers planned or intentional development and its relationship with global health. In particular, we argue that the SDGs do not adequately tackle the problems created by immanent development—i.e., inequality and environmental destruction—and that this has potentially catastrophic implications for global health. We conclude on a more optimistic note, arguing that the enormity and proximity of the threat posed to the current world order by climate change and inequality might force powerful interests to enact changes that will benefit global health.

Immanent or Unintentional Development For most of human history the majority of people have lived close to subsistence level. Income levels fluctuated as a result of wars, famines, and pestilence, but over the longue

Global Health and International Development   219 durée they grew at a rate that was able to support a slowly rising world population (Milanović 2016). Nor was there a great difference in income levels between different countries and regions. The ‘European Miracle’ (Jones 1981) began in the ‘long 16th century’ (Wallerstein 1974), but the most rapid period of divergence was the nineteenth century (Pomeranz 2000). This period of economic growth, which Karl Polanyi (2001) refers to as the ‘Great Transformation,’ occurred as a result of a number of processes that transformed politics, economics, and society, culminating in the mode of production that we refer to as capitalism. As Polanyi points out, prior to this transformation the economy was subordinated to politics, religion, and social relations. But the economy became increasingly disembedded from society, as the burgeoning capitalist class and classical political economists—most notably Thomas Malthus and David Ricardo—pushed the state to create an economic system that subordinated society to the logic of self-regulating markets. Previously, people had made decisions based on considerations of tradition, reciprocity, and redistribution; but in a ‘market society’ individuals acted as rational utility maximisers, motivated by the desire to make profit by incessantly appropriating nature, exploiting labour, and investing and accumulating capital.

The Great Transformation and the Great Divergence Even critical political economists such as Marx and Engels (1848) and Polanyi (2001) concede that capitalism has brought massive increases in productivity and wealth. A market society is nevertheless problematic because it treats nature and labour as commodities (i.e., as if they have no value except their market value), and this leads to relentless exploitation with minimal concern for the social and environmental consequences (Polanyi 2001; Moore 2017). The agricultural and industrial revolutions were made possible by enclosure, a euphemism for a process of primitive accumulation in which the dominant rural classes, with the state’s support, expelled peasants from land that they had farmed for generations (Brenner 1977). Enclosure enabled the introduction of new techniques and technologies that markedly increased land productivity, but it also created a landless proletariat that was separated from the means of subsistence and therefore had to sell its labour to industrialists in rapidly growing cities or else starve. The great transformation therefore created massive inequality within industrialising countries, and this had important implications for health. Until the mid-nineteenth century, industrial workers’ earnings were less than their pre-industrial peers’ (Engels 1845; Moore 2017). Living in crowded and insanitary conditions, mortality rates for the industrial proletariat were higher than for those living in the countryside, as well as for other classes living in the cities (Engels 1845; Chadwick 1842). Indeed, according to official statistics, life expectancy in the United Kingdom fell between 1841 and 1851, the first decade for which statistics are available (Office for National Statistics 2015). The great transformation also created the current division of the world into the ­relatively prosperous global North and relatively poor global South. In 1500 there were

220   Andrew Harmer and Jonathan Kennedy not great disparities in socio-economic development between countries and regions (Milanović 2016). In many ways, the Aztec, Inca, Arab, Chinese, and Mughal civilisations were more technologically advanced than Europe around this time (Acemoglu, Johnson, and Robinson 2002). Even in 1750, India and China together accounted for almost three-quarters of world industrial output (Tharoor 2017, p. 216). But colonialism led to a “reversal of fortune” as Europe and its settler colonies became the most  prosperous regions in the world (Acemoglu, Johnson, and Robinson 2002). For states at the sharp end of the colonial project, the consequences for health were catastrophic. Latin America saw its population reduced by 95 percent between 1492 and the mid-1600s at the hands of the Spanish conquistadors (Zinn 1980). India went from producing 23 percent of world economic output in 1600 to 3 percent by 1947 and ‘was transformed by the process of imperial rule into one of the poorest, most backward, illiterate and diseased societies on earth by the time of . . . independence’ (Tharoor 2017, 216).

Globalisation and Inequality Globalisation has been defined as the ‘broadening, deepening and speeding up of world-wide interconnectedness in all aspects of life’ (Held et al. 1999, 2). It is not a new phenomenon; Therborn, for example, identifies six waves of globalisation, beginning with the diffusion of world religions and the establishment of transcontinental civilisations in the period 300–600 CE (Therborn 2000). Here we focus on its most recent, primarily economic, incarnation, which began in the 1980s (see also Sparke in this volume). Sustained economic crises in advanced economies during the preceding decade resulted in increased dissatisfaction with the Keynesian macroeconomic policies that had been dominant since the 1930s. The reaction against state intervention was led by what Ha-Joon Chang (2003) has referred to as an ‘unholy alliance’ between neoclassical economics and the Austrian-Libertarian political philosophy. This pro-market ideology was advocated by economists such as Friedrich von Hayek and Milton Friedman and came to be known as neo-liberalism. Its tenets are well known and strongly shape the latest stage of globalisation: limited government, free trade, liberalisation of capital markets, and privatisation of public enterprises and services (Stiglitz 2002). Neoliberalism pushed for a return to the laissez faire economic policy of which Polanyi was so critical (Block and Somers 2014). The effects of this shift in terms of the state’s ability to provide security for those in its charge has become a central concern for international relations’ scholars (Held et al. 1999; Scholte 2000). In the United States and United Kingdom these ideas were championed by Ronald Reagan and Margaret Thatcher respectively; they were exported through the Washington Consensus, named after institutions that were based in DC such as the International Monetary Fund (IMF), World Bank, and US Treasury Department. Thus it is apparent that the long-term process of social change that is often described as immanent or unintentional and is

Global Health and International Development   221 contrasted with planned or intentional development in the literature, is in fact subject to a large degree of intentional planning. The rationale for such a shift in economic policy was clear enough, if now refuted empirically: the benefits of economic globalisation would accrue to all people and countries—eventually—through a process known as ‘trickle down’. A rising tide, as the aphorism goes, lifts all boats. This assertion has underpinned analyses looking to answer the question of whether economic globalisation has been good for global health (Dollar 2001; Feachem 2001; Weisbrot et al. 2006; Labonté and Schrecker 2007). In an early study, Dollar (2001, 832), for example, concluded: ‘The bottom line is that global ­economic integration can be a powerful force for increasing incomes and hence improving health and other aspects of welfare’. But five years later, a review of the ‘scorecard’ of globalisation against a range of social indicators—growth of income per person; life expectancy; mortality amongst infants, children, and adults; literacy; and education— came to the opposite conclusion: ‘The past 25 years in low- and middle-income countries have seen a sharp slowdown in the rate of economic growth, as well as a decline in the rate of progress on major social indicators including life expectancy and infant and child mortality’ (Weisbrot et al. 2006, 1). Although globally life expectancy increased by approximately twenty years between the 1950s and early twenty-first century, this was not the case in all regions of the world (Rowden 2009). Moreover, a variety of examples show how neo-liberal globalisation has had detrimental effects on health. In particular, criticism has focused on the structural adjustment programmes (SAPs) adopted by the World Bank and the IMF during the 1980s to advance development. These programmes reinforced the neo-liberal globalisation project, but with devastating consequences for healthcare in many countries seeking loans for development purposes (see Sparke in this volume). Sub-Saharan Africa, for example, experienced a decline in life expectancy from fifty to forty-six years (UNDP and World Bank data, quoted in Rowden 2009, 153). Country-specific data were more damning, with a sixteen-year decrease in South Africa (from sixty-two to forty-six years) and a fifteen-year decline (from fifty-six to thirty-nine years) in Zimbabwe during those decades of the most intense implementation of neo-liberal development policies (1980–2003) (Stein, quoted in Rowden 2009, 153). Rowden’s survey of the healthcare literature published during the 1980s and 1990s provides extensive evidence of both the extent and degree to which healthcare spending fell following the adoption of neo-liberal SAPs. Stein’s analysis of twelve sub-Saharan African countries reveals an average real per capita decline of approximately 20 percent in health expenditure (Stein, quoted in Rowden 2009, 154–155). Although some studies of neo-liberal policy have reported positive gains (Gerring and Thacker 2008; Gupta 2010), their conclusions are unpersuasive against a growing body of work documenting the negative effects of such policies on the health of nations (Navarro 2007; Stuckler and Basu 2013; Rowden 2009; Sparke 2017). The post-Soviet mortality crisis is a stark example. After the fall of the communist system in the former Soviet Union, radical free-market reforms or ‘shock therapy’, advocated by Friedman,

222   Andrew Harmer and Jonathan Kennedy amongst others, were undertaken. This therapy entailed removing state control of prices, wages, and so forth, and replacing it with the market and privatisation of state-owned enterprises.1 Whilst the transition to capitalism enriched a small group of politically well-connected businessmen who gained control of former state-owned enterprises, it also led to a great deal of economic and social disruption as companies that had previously provided a cradle-to-grave social protection system were stripped of their assets and closed down. Gross domestic product (GDP) fell by more than one-third, by 2000 one-quarter of the population lived on less than a dollar a day, and unemployment increased from 0 percent under communism to 22 percent in 1998 (Stuckler and Basu 2013). The health effects were also catastrophic; life expectancy amongst Russian men dropped from sixty-four to fifty-seven years (Stuckler and Basu 2013). The proximate causes of death were suicide, homicide, and drug and alcohol abuse, leading to an increase in cardiovascular and liver diseases. These occurred primarily amongst working age men who, having lost their jobs, turned to drugs and alcohol, harming themselves and others (Stuckler, King, and McKee 2009). Nationally, support for the privatisation of healthcare—a strategy rooted in neo-liberal economic theory—has resulted in very poor health outcomes, particularly for the poorest (Navarro 1993; Waitzkin 2000). In particular, the introduction and implementation of user fees—a corollary of the privatisation of health services—has been decried by public health experts (WHO 2008), with many studies concluding that user fees have decreased coverage and access to health services (McPake et al. 2011; Watson et al. 2016). Others have been more vocal in their criticism of the policy, with Rowden suggesting that compensation should be sought by those whose health was impaired as a result of the implementation of user fees (Rowden 2013). What is most relevant to the present discussion, however, is the role of international development donors in introducing user fees ‘despite early warnings about the detrimental effect of such policies on health-care access for poor people’ (Bärnighausen 2015, 685). Salman Keshavjee describes international donors’ uncritical support for user fees in his book Blindspot, in which he argues that international development actors—both states and NGOs—were guilty of ‘programmatic neoliberal blindness’ (Keshavjee 2014, 15).

Globalisation and Human-Induced Climate Change The term Capitalocene has been coined to signify that it is the capitalist system rather than humanity per se that is responsible for environmental destruction (Moore 2017). Capitalism requires the appropriation and exploitation of nature in order to provide cheap food, energy, and raw materials (Moore 2017), and critical political economists have long argued that an economic system in which the primary objective is the endless pursuit of profit will have a catastrophic effect on the environment. As early as the mid-nineteenth century, Karl Marx pointed to a phenomenon that he called a ‘metabolic rift’, in which land became depleted of nutrients as it was intensely farmed to meet the

Global Health and International Development   223 needs of the growing urban population, and rivers were polluted by human sewage and industrial waste (Foster 1999). Concerns about the environmental consequences of capitalism have, however, become mainstream in the past few decades. In Limits to Growth, for example, a group of economists used early computer modelling to illustrate, and warn against, what they termed ‘overshoot’ of our planet’s resources (Meadows et al. 1972). The title of the update to their study twenty years later—Beyond the Limits— portrays the extent to which such warnings fell on deaf ears. In 1987 the Brundtland report, Our Common Future, popularised the phrase ‘sustainable development’ and called for ‘development that meets the needs of the present without compromising the ability of future generations to meet their own needs’ (World Commission on Environment and Development 1987, 43). In 2009 the concept of planetary boundaries was introduced (Rockstrom et al. 2009), which identified and quantified what the authors termed ‘an operating space’ within which all life on earth could safely continue to exist. Alarmingly, against a range of criteria, that boundary had been exceeded or was in imminent danger of being so. Finally, Kate Raworth’s (2017) book, Doughnut Economics, builds on Rockstrom et al.’s analysis and proposes a system of production and consumption that marries human prosperity with ecological sustainability. Raworth (2017, 50) argues that ‘human thriving depends on planetary thriving’: sufficient food requires nutrient-rich soil, safe water to drink requires plentiful rainfall, clean air to breathe requires reductions in air pollution, and so forth. Without that relationship, the prospects for humans, let alone human development, become increasingly dim. In 2014 the Intergovernmental Panel on Climate Change (IPCC) reported that each of the last three decades has been successively warmer than any preceding decade, and 2014, 2015, and 2016 were the hottest years on record. The global average temperature is already 0.85°C above pre–Industrial Revolution figures (IPCC 2014). Although the consequences for human health of climate change have been documented since 1990, that relationship has only received significant attention since 2006 (Verner et al. 2016). Clearly, human health is inextricably linked to a hospitable environment, and human beings are extremely vulnerable to a host of climate change effects. Whilst there may be benefits to some in the short term, as McMichael, Montgomery, and Costello conclude: ‘The overall balance of health impacts of climate change . . . is anticipated to be substantially, and increasingly, negative’ (2012, 26). Research into the health effects of climate change has increased exponentially, and those effects are now well understood (Watts et al. 2015). Climate change is now seen as ‘the biggest global health threat of the 21st century’ and ‘threatens to undermine the last half century of gains in development and global health’ (Costello et al. 2009, 1693; Watts et al. 2015, 1861). Climate change affects health directly, through increased heat waves and extreme weather events, and indirectly as a result of its effects on ecosystems. Examples of the latter include the spread of disease vectors, food insecurity and undernutrition, and displacement and conflict (Watts et al. 2015). What is more, these effects are likely to be particularly negative for vulnerable groups such as women and the poor.

224   Andrew Harmer and Jonathan Kennedy

Planned or Intentional Development In this section we consider whether planned or intentional development is able to resolve intra- and international inequalities in health, and the potentially catastrophic climate change effects created by unplanned or immanent development. The formal practise of international development, whereby wealthy nations agree amongst themselves to a set of rules, goals, and conditions for assisting less wealthy nations to develop, is a relatively recent feature of economic and political relations between states. In 1948 the United States initiated the Marshall Plan, which gave 2.5 percent of GDP to rebuild war-ravaged Western European economies. The plan was seen as a remarkable success and influenced the idea that similar results could be achieved if the wealthy countries gave aid to less prosperous nations (Szirmai 2017). Aid from the Marshall Plan was administered by the newly established Organisation for European Economic Cooperation (OEEC), which in 1961 became the Organisation for Economic Co-operation and Development (OECD)—an organisation comprised of OEEC countries plus the United States and Canada, and with a global rather than European focus. A few years earlier, the International Bank for Reconstruction and Development (later to become incorporated into the World Bank group) and the IMF, were established to help with reconstructing war-wrecked economies and providing financial stability. These institutions would go on to have an enormous effect on international development. One of the most significant agreements made by members of the OECD was to commit a percentage (0.7 percent) of their economic output—gross national product (GNP)—to official development assistance (ODA). However, only a handful of countries met this commitment: the OECD average is less than half at 0.32 percent, and the United States, the largest international donor in absolute terms, gives just 0.19 percent (OECD 2018). The OECD has also worked since the 1960s, through its Development Assistance Committee (DAC), to agree to the rules and norms that govern the system of international development that we see today. Between 2003 and 2011 the OECD coordinated a series of high-level international meetings aimed at aid effectiveness, which provide a framework for describing, measuring, and evaluating efforts to govern international and, with the advent of multiple nonstate financial actors, global development ­assistance (OECD n.d). Initially WHO was the undisputed leader of global public health programmes. WHO’s focus was primarily on international health—that is, stopping the transition of infectious diseases across borders—but it also undertook a variety of interventions to improve health in the global South (see chapter by Cueto in this volume), the most notable success of which was the eradication of smallpox in 1980 (Brown, Cueto, and Fee 2006). The World Health Assembly (WHA), WHO’s main decision-making body, works on the basis of one vote per member state. As an increasing number of former colonies joined the UN system, WHO’s policies became more radical, culminating in the AlmaAta declaration of 1978, which identified primary healthcare as crucial to improvement

Global Health and International Development   225 in health in the developing world. The United States and its allies in the WHA responded by freezing their compulsory contributions to WHO and pursuing their health agenda through a number of other routes. This included a marked increase in their voluntary contributions to WHO, which allowed donor states rather than WHO to decide how these monies would be spent. A second route was through the development agenda of the World Bank and IMF, which began to have an increasingly important impact on global health. Crucially, the United States and its allies were more able to control the way that these two institutions spent their money because voting rights were linked to the size of contributions: the greater the subscription, the more political power a country wields within the organisation. The World Bank and IMF formed part of the so-called Washington Consensus, which forced neo-liberal policies on much of the global South through SAPs and in post-Soviet societies through shock therapy. In 1990 development assistance for health (DAH) totalled US$5.7 billion. This amount doubled and tripled with each successive decade; by 2010 DAH had increased to US$28.2 billion (IHME 2013). The twenty-first century marked a shift away from multilateral financing of health and towards public-private global health partnerships (such as the Global Fund and the vaccine alliance GAVI), as well as bilateral financing of health projects, notably the US President’s Emergency Plan for AIDS Relief (PEPFAR) (Harmer and Spicer 2014). At the same time, the Gates Foundation—an organisation that is not accountable to anyone but Bill Gates, his family, and its largest donor, Warren Buffet—has become an increasingly important player in international development and global health (McCoy et al. 2009; see Youde in this volume). For many commentators, the first decade of the new century was the ‘golden age’ of global health: a short period of time during which it enjoyed unprecedented economic and political support. In 2011, however, DAH fell, and although in absolute terms it continues to grow (in 2016 total DAH was $37.6 billion), the most recent analysis concludes that its growth has stagnated (IHME 2017). It is instructive to reflect on the total amount of development assistance for health: $37.6 billion. It is a considerable sum, and in some commentators’ view it has been used effectively to save millions of lives (Glassman and Temin 2016). Critics of development assistance have been less effusive in their assessment of what it has achieved (Easterly 2006; Rist 2007). Moreover, that figure represents approximately 29 percent of the total aid given by rich to poor countries ($128 billion in 2016) or 0.02 percent of all aid, investment, and income from abroad that flowed to developing countries in 2012 ($2 trillion) (Hickel 2017, 24–25). But how much aid, investment and income flows out of developing countries? Answer: a staggering $5 trillion in 2012 (Hickel 2017, 24–25). It is possible to partially disaggregate this outflow: $200 billion is interest on debt repayments; $500 billion is repatriated profits from investment; $60 billion is payments to foreign owners of patents; $973 billion is leakages in balance of payments; and $875 billion is ‘trade misinvoicing’ (Hickel 2017, 25–27). The point is not a subtle one: with one hand, wealthy donors give a tiny amount of money to help poor countries improve the health of their populations; with the other, the very same donors take an almost incomprehensibly large amount of money out of those poor countries’ economies.

226   Andrew Harmer and Jonathan Kennedy According to the OECD’s own analysis, efforts to make aid more effective have resulted in tangible benefits for health sectors globally (OECD 2012). In 2010, however, an influential paper published in the Lancet reported what was to many commentators at the time an astonishing result: the amount of DAH being channelled towards countries in need of development assistance was beginning to affect the way those governments spent money on their health systems (Lu et al. 2010). For every US$1 of DAH given to a government, government health expenditures from domestic resources fell by between $0.43 and $1.14. This ‘crowding out’ of health resources, or fungibility, left scholars scratching their heads. Why would governments do this: spend less of their own money on health? One hypothesis was that ‘governments compensate for exceptional international generosity to the health sector by reallocating government funding to other sectors’ (Ooms et al. 2010, 1403). The point is not to ridicule the notion of generosity; the point is simply to provide a sense of perspective. If international donors are taking at least $2.6 trillion from poor countries every year, it hardly matters whether for every $1 of DAH received, those countries spend $.50 less on their health systems.

The Goals of Contemporary International Development The significance of health for contemporary international development efforts was reflected in the MDGs, announced at the Millennium Summit in September 2000. All 191 UN member states committed to help achieve the eight targets by 2015 (see table 12.1). Three targets specifically focused on health: to reduce child mortality; improve maternal health; and combat HIV/AIDS, malaria, and other diseases—whilst the other five referred to important determinants of health. At their conclusion in 2015, the MDGs were described by Ban Ki-Moon as ‘the most successful anti-poverty movement in history’ (UN 2015). Claims about their success are based on the assumptions that they resulted in an increase in aid and that this aid was used effectively to achieve the targets (Kenny and Sumner 2011). Regarding the first assumption, there was an increase in aid during the period: the proportion of aid to gross national income (GNI) given by OECD Table 12.1  UN Millennium Development Goals, 2000–2015 The eight Millennium Development Goals are 1. to eradicate extreme poverty and hunger; 2. to achieve universal primary education; 3. to promote gender equality and empower women; 4. to reduce child mortality; 5. to improve maternal health; 6. to combat HIV/AIDS, malaria, and other diseases; 7. to ensure environmental sustainability; and 8. to develop a global partnership for development. Source: http://www.who.int/topics/millennium_development_goals/about/en/.

Global Health and International Development   227 countries fell from 0.33 percent in 1990 to 0.22 percent in 2000 (Sachs 2005), but began to change at the turn of the millennium, and by 2016 OECD countries gave an average 0.32 percent (OECD 2017). Nevertheless, it has been argued that this increase was due to other factors, most notably the fallout from the War on Terror, which saw the United States and its allies increase their donations in order to win the support of regimes in North Africa, the Middle East, and South Asia. The evidence for the second assumption, that increased aid was effective in helping countries meet the MDGs, is weak. First, some goals were not reached. For example, based on current trends it is estimated that child mortality will not fall by two-thirds until 2025 (Jack 2015). Second, the MDGs seem to have played little role in other targets being met: the fall in global poverty was to a considerable extent the result of economic growth in China, which had nothing to do with foreign aid or the MDGs (Cimadamore, Koehler and Pogge 2016; Hickel 2016). Third, declines in child and infant mortality began before 2000 and showed no statistically significant improvement after the Millennium Declaration (Friedman 2013). And fourth, although countries that made faster-than-expected progress in child mortality received more aid than those countries that did not in the period 2001 to 2010, the results are not statistically significant (Kenny and Dykstra 2013). In spite of the uncertain results of the MDGs, they were succeeded by another set of global development goals, the SDGs (see table 12.2). On September 25, 2015, all 193 UN member states committed to achieving them by 2030 (UN n.d.). The SDGs are much broader than the MDGs, consisting of 17 goals and 169 targets. Health is the explicit focus of SDG 3—to ‘Ensure healthy lives and promote well-being for all at all ages’—and is backed up by thirteen targets and four mechanisms that cover a wide range of global health issues (UN n.d.). In addition, almost all of the other 16 goals are related to health or the broader determinants of health in some way or other. These include SDGs 10 and 13, which call for reduced inequalities and climate action, respectively. The scale, scope, and ambition of the SDGs is remarkable, covering issues such as poverty, employment, hunger and malnutrition, access to secondary and tertiary education, gender discrimination and violence, housing, water, sanitation, energy, communications technology access, marine pollution, and species loss. Supporters argue that the scale and scope are more suited to bringing about meaningful development, because they reflect the complexity of the problems that the SDGs aim to resolve (Sachs 2015). But critics such as the Economist (2015) argue that they are ‘sprawling and misconceived’, whilst others have criticised the ‘encyclopaedic’ range of goals and targets such that ‘everything is top priority, which means nothing is a priority’, thus rendering them ‘worse than useless’ (Easterly 2015). If health in the SDGs was ready for a ‘paradigm shift’ as some observers noted, it didn’t get it (Buse and Hawkes 2015). It is argued that open working groups and ‘global conversations’ made SDG planning the ‘largest consultation programme in UN history’ (Dearden 2015). The process of priority setting was arguably better than the MDG approach, in which a handful of men—the World Bank’s Eric Swanson, OECD-DAC’s Brian Hammond, and UNDP’s Jan Vandemoortele—wrote the goals in secret

228   Andrew Harmer and Jonathan Kennedy Table 12.2  UN Sustainable Development Goals, 2015–2030 1. 2. 3. 4.

End poverty in all its forms everywhere. End hunger, achieve food security and improved nutrition, and promote sustainable agriculture. Ensure healthy lives and promote well-being for all at all ages. Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all. 5. Achieve gender equality and empower all women and girls. 6. Ensure availability and sustainable management of water and sanitation for all. 7. Ensure access to affordable, reliable, sustainable, and modern energy for all. 8. Promote sustained, inclusive, and sustainable economic growth; full and productive employment; and decent work for all. 9. Build resilient infrastructure, promote inclusive and sustainable industrialisation, and foster innovation. 10. Reduce inequality within and amongst countries 11. Make cities and human settlements inclusive, safe, resilient and sustainable 12. Ensure sustainable consumption and production patterns 13. Take urgent action to combat climate change and its impacts* 14. Conserve and sustainably use the oceans, seas and marine resources for sustainable development 15. Protect, restore and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification, and halt and reverse land degradation and halt biodiversity loss 16. Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at all levels 17. Strengthen the means of implementation and revitalise the global partnership for sustainable development Source: http://www.un.org/sustainabledevelopment/sustainable-development-goals/

(Fukuda-Parr and Hulme 2009). Nevertheless, the SDG terms of engagement were decided in advance (without wide public engagement), whilst polls encouraged participants to prioritise those preselected development issues. More serious criticisms of the SDGs refer to their internal contradictions and the fact that the goals do not address the source of the problems that they aim to resolve—that is, the global economic system that has created massive inequalities and potentially catastrophic climate change (Hickel 2015). The SDGs are informed by Ban Ki-moon’s assertion that ‘there can be no Plan B, because there is no Planet B’ (UN 2013). They focus on ‘the challenges of ensuring more equitable development and environmental sustainability, especially the key goal of curbing the dangers of human-induced climate change’ (Sachs 2015). Specifically, the SDGs endorse the aim of keeping global temperature change to below 2 degrees Celsius and advocate ‘sustainable patterns of production and consumption’. Nevertheless, they continue to endorse the system of growth-focused economics that commodifies the environment and created climate change. For example, SDG 8 is focused on economic growth and calls for annual GDP growth of at least 7 percent in low-income countries (LICs). Moreover, SDGs promote growth as the main solution to poverty reduction, but the evidence suggests that this assumption is highly problematic. The poorest 30 percent of

Global Health and International Development   229 the world’s population received just 1.2 percent of all the income generated by global GDP growth between 1999 and 2008, whilst the poorest 60 percent received 5 percent (Woodward 2015). Given the existing ratio between GDP growth and the income growth of the poorest, it would take between 123 and 209 years to eliminate poverty and require an increase in the size of the global economy by a factor of 175, at which point GDP per capita would be $1.3 million. This is clearly implausible. The obvious, but politically unpalatable, solution is for the wealthiest people in the world to reduce their consumption. However, the SDGs merely tinker with a system that does not work to reduce poverty and promote health globally, rather than challenging the system itself (Hickel 2015).

Conclusion The analysis set out in this chapter makes rather depressing reading. We argue that immanent or unintentional development, of which economic globalisation is just the latest stage, has resulted in massive inequalities and potentially catastrophic climate change. The unregulated capitalist economic system is wreaking havoc with human and planetary health, to the extent that it threatens the existence of life on earth. Furthermore, inequality and climate change are not adequately addressed in the most recent iteration of the planned or intentional development agenda. The SDGs, the primary policy response, are not fit to resolve—indeed fail to acknowledge—the contradictions of capitalism and the dangers it presents. Nevertheless, there are still grounds for optimism. Climate change is not only the greatest threat to global health but also, as the recent Lancet Commission pointed out, its greatest opportunity (Watts et al. 2015). It is possible that the problems created by climate change will become so overwhelming and pressing that the powerful interests that presently oppose fundamental political and economic transformations will have little choice but to acquiesce. It might seem apparent that the rising levels of inequality in advanced capitalism do not pose the same existential threat to human civilisation as climate change. Indeed, 170 years after the publication of the Communist Manifesto, Marx’s prediction that the bourgeoisie’s exploitation of the proletariat and ever-increasing accumulation of capital would lead to the former’s downfall at the hands of the latter has not yet come true. Nevertheless, intranational inequality has reached levels not seen since the nineteenth century, and there is growing consensus that something needs to be done (Piketty 2014; Milanović 2016). Even the World Economic Forum in Davos argued that increasing wage and income inequality poses the greatest risk to the world economy over the next decade (World Economic Forum 2017). Echoing Italian political theorist Antonio Gramsci, Wolfgang Streeck (2016) has suggested that society is entering a post-capitalist ‘interregnum’, a period of uncertain duration in which the old economic order is dying but a new one has yet to be born. It is not clear at present what form the next order will take. It is possible that we will experience what Polanyi referred to as a countermovement—that is, a retreat from market

230   Andrew Harmer and Jonathan Kennedy capitalism in order to save society and nature from annihilation. Nevertheless, this should not be taken for granted. There are numerous historical examples of societies collapsing because they did not take action to prevent destroying their own environments, including the Polynesians on Easter Island and Pitcairn Island, the Anasazi of southwestern North America, and the Maya of Central America (Diamond 2005). Economists have played a key role in the formation of the previous modern politicaleconomic orders—Malthus and Ricardo with nineteenth-century liberalism, John Maynard Keynes in the middle of the twentieth century with social democracy and the developmental state, and von Hayek and Friedman with late twentieth- and early twenty-first-century neo-liberalism. It therefore makes sense to look to current economists for ideas about what a future political-economic order could be. Jason Hickel has argued that the world as a whole needs to undergo a process of ‘intentional de-growth’ in order to reach a ‘steady-state’ that maintains economic activity at ecological equilibrium. This would involve reducing resource consumption and instead focusing on things that really matter, such as health, well-being, longevity, and education. Whilst this might seem utopian, it is not; for example, Europe’s human development indicators are generally higher than those of the United States, but its GDP per capita is 40 percent lower and emissions per capita are 60 percent lower. Kate Raworth argues for an economy that is embedded in the earth’s systems and in society. The main goal of such an economy would not be growth but providing sufficient supplies of the resources necessary to lead a good life without overstepping the earth’s environmental limits—that is, living in an ‘ecologically safe and socially just space’ and ‘meeting the needs of all within the means of the planet’ (Raworth 2017). Such an economic system would address the major threats to global health far more effectively than the current international development regime that is informed by the SDGs.

Note 1. The scale and speed of privatisation was remarkable. Margaret Thatcher privatised about twenty large British utility companies in eleven years as prime minister, whilst in postSoviet Russia more than 200,000 Soviet enterprises were privatised in less than five hundred days (Stuckler and Basu 2013).

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chapter 13

The Politics of Gen der a n d Gl oba l  H e a lth Sarah Hawkes and Kent Buse

The idea that there might be differences in the health and survival experiences of men and women, boys and girls has been explored since at least the seventeenth century. In 1662 John Graunt (Graunt 1662) analysed baptism and death records in churches in London and an English rural county. He noted that men suffered a survival disadvantage and attributed this to their being ‘more intemperate then (sic) women, [and] die as much by reason of their Vices’. Men were also noted to be more likely to be ‘slain in wars, killed by mischance, drowned at sea’. Women, meanwhile, might be living longer than men, but Graunt recorded that they were more likely to be sick from ‘Breedings, Abortions, Child-bearing, Sore-breasts, Whites, Obstructions, Fits of the Mother, and the like.’ Aside from being recognised as the ‘grandfather of epidemiology’, Graunt could also be credited with being amongst the first scholars to record differences in survival chances between men and women and also to note that some of those differences are likely driven more by behaviour than biology. By the twentieth century, feminist philosophers had firmly established the notion inherent in Graunt’s work, that the life, survival. and well-being pathways of men and women are driven by more than biological determinism alone. In other words, the risks (and mitigating strategies) to which people are exposed throughout life contribute to their likelihood of survival. Whilst not the first, nor last, feminist to note the impact of socially constructed roles, expectations, and opportunities, particularly on the lives of women, Simone de Beauvoir, in her seminal work The Second Sex (de Beauvoir 1949), elaborated on the notion that being a ‘woman’ was predicated more on the nature of social relationships than on biological and physiological status—in other words, on ‘gender’. By the 1950s the possibility that these socially constructed roles may play a part in health and well-being was further developed in the realm of medicine through the work of American psychologists John Money and his colleagues. They drew a distinction

238   Sarah Hawkes and Kent Buse between sex and gender to differentiate between physical and psychological characteristics. According to Money, gender, experienced privately, is ‘gender identity’—an individual’s self-perceived and self-identified sense of being male or female—and expressed publicly through ‘gender roles’ (Money  1957; Money  1973). Money’s ideas took decades to be accepted in many parts of the health sector, but in the realm of medical research the use of ‘gender’ now outstrips ‘sex’ in several areas of academic publishing (Haig 2004). In this chapter we ascribe firmly to the notion that gender, embodied through distributions of power and the relational nature of social interactions between people, is a social construct (Connell 2012) that bears a significant effect on the health and wellbeing of all people (Hawkes and Buse 2013). Gender, as a social construct, encompasses both patterns of social organisation as well as ascribed roles and positions in society that people may occupy on the basis of having a particular gender identity. Gender, as described by Lorber (1994), is a ‘major building block in the social structures built upon unequal statuses’, but it also describes a ‘process [that] creates the social differences that define “woman” and “man”’. We use the UN Women (n.d.) definition of gender as referring to ‘the roles, behaviours, activities, and attributes that a given society at a given time considers appropriate for men and women’. This definition goes on to recognise that ‘[t]hese attributes, opportunities and relationships are socially constructed and are learned through socialization processes. They are context- and time-specific and changeable. Gender determines what is expected, allowed and valued in a woman or a man in a given context’ (UN Women n.d.). Gender is embedded in unequal power relations—relationships that have historically emphasised women’s lower social position and status. Gender equality is recognised as a human right and has been at the core of global action and attention since at least 1946, the year that the United Nations Economic and Social Council (ECOSOC) established the Commission on the Status of Women (CSW). One aim of CSW was given as ‘preparing recommendations and reports to the ESOCOC to promote women’s rights in political, economic, social and educational fields’ (Sustainable Development Knowledge Platform n.d.). Gender inequality, aside from being an abuse of human rights, has direct and measurable effects on many social and economic outcomes, including health and well-being. The 2008 the World Health Organization (WHO) Commission on the Social Determinants of Health, for example, gave a clear description of the relationship between women’s unequal position in many societies and their (lack of an) ability to realise their rights to healthy lives (Marmot et al. 2008). However, gender is not synonymous with ‘women’ or ‘girls’, and the gendered roles that men occupy in most societies tend to also be associated with increased risks to their health and well-being—mediated, for example, through gendered norms of risk-taking behaviours (use of tobacco and alcohol). Evidence of the lower life expectancies and poorer health outcomes for men (compared to women) has accrued for centuries; in both England and Wales, and Sweden, men’s lower life expectancies have been systematically recorded since at least the nineteenth century (e.g., see Villegas et al. 2014 for England Statistics Sweden 2010). Analysis of birth cohort data from thirteen economically developed countries (in Europe and North America) found an increase in adverse male to female mortality ratios (particularly in the age group 50–70 years) since 1880.

Politics of Gender and Global Health   239 Globally, life expectancy has risen in all countries in the past fifty years, but progress has not been as pronounced for men as for women in many places (GBD 2017 Mortality Collaborators 2018). Beyond life expectancy, evidence of men’s higher disease burden for most major health conditions has been reported for over twenty-five years. The first calculations of the global burden of disease (GBD) reported in the World Development Report (World Bank 1993) found that ‘females have about a 10 percent lower disease burden per 1000 population than males for the world as a whole’, whilst also noting that ‘female advantage ranges from 30 percent in the formerly socialist economies, where adult mortality is much higher for men than for women, to negative in India, where females suffer a disadvantage of 8 percent’. Much of this additional burden (and re­sult­ant earlier deaths) is driven by different rates of exposure to harm-producing environments, consumer products, and expectations of behaviour. Men’s occupations, rates of harmful behaviours, and levels of violence are associated with the gender norms and gendered expectations of masculinity in many societies—and these associations carry significant implications for outcomes of men’s well-being, health, and survival. Conversely, whilst women on average have a higher life expectancy than men, they also spend more years living in poor health, particularly as a result of suffering from ‘disabling conditions’ such as musculoskeletal disorders (Kyu et al. 2018). Within the health system, the effects of gender (in)equality are also seen in relation to career opportunities—summarised as women bearing the major responsibility for the delivery of health and social care, whilst organisations are predominantly led and governed by men (Global Health 50/50 2018, 2019). Despite the overwhelming evidence of gender inequality exerting a major burden of negative outcomes on health, well-being, and career progression for all people in all countries, until now the question of gender has not been placed high on the agendas of many organisations working in the field of health. In this chapter we explore the possible reasons for this, including contested definitions and the lack of a cohesive policy community. First, however, we provide a conceptual framework within which we review the strength of the relationship of gender, gender inequality, and health inequity, and then summarise the history of institutional responses to gender in the field of global health. We end by highlighting opportunities for change to ensure that health organisations, and people working within the health sector, become more gender responsive—thereby reducing health inequity, tackling gender inequality, and promoting the rights of all people to the ‘highest attainable stand­ ard of health’ (WHO 1948).

Gender and Health: A Conceptual Framework Gender is distinct from but interacts with biological sex. Biological sex (ascribed at birth based on the presence of male or female genitalia, occasionally resulting in a category of ‘intersex’ when genitalia are ambiguous) has a significant influence on health

240   Sarah Hawkes and Kent Buse outcomes and contributes to differences in morbidity, mortality, and life expectancy. Such biologically based drivers of the health differences between men and women, boys and girls can be seen in domains as diverse as how the immune system responds to foreign and self-antigens (Klein et al.  2015) and how individuals metabolise alcohol (Thomasson et al. 1995). Some people experience an incongruence between biological and gender identities, and they may self-identify, or be labelled, as transgender, or trans (Winter et al. 2016). The health experiences of trans people are significantly influenced by their status on the ‘gender spectrum’ and their interactions with health systems (Wylie et al. 2016) and are explored in more depth later in the chapter. With these definitions as a starting point, we draw on a conceptual framework of the interactions between gender and health outcomes that sees the relationship occurring in three interlinked domains: gender and other social determinants of health, gender and health behaviours, and gender and system responses (Doyal and Payne  2011; Hawkes and Buse 2013). We explore all three domains—see Figure 13.1—and review how the politics of global health organisations has influenced their responses to demands for gender equality and health equity.

Gender Intersects With Other Social Determinants of Health Gender interacts with other social determinants of health to both reproduce inequalities and promote privilege and opportunity. Crenshaw (1989) describes the interaction Framework for understanding and addressing role of gender on health and wellbeing Gender intersects with other health determinants Gender is embodied differently through its interaction with other social determinants of inequality and vulnerability, e.g. poverty, occupation, education, geography and participation. Gender inequality and discrimination can have direct negative effects on health and wellbeing.

Gender equality and health equity

Social, economic and commercial determinants

Institutions and systems

Gendered institutions Gender is embedded in institutions. Gendered policies and practices influence peoples’ experienses of organisations and systems (health, legal, political, economic, social welfare, etc).

GENDER

Behaviours

Gender and health behaviours Gender is enacted through behaviours. Gender norms, roles and expectations influence behavioural patterns of risk, vulnerability and protective behaviours.

Figure 13.1  Conceptual framework illustrating the relationship between gender and health and well-being.

Politics of Gender and Global Health   241 of multidimensional axes of discrimination (predominantly race and gender) as ‘intersectionality’ and proposes a means of critiquing existing social orders through a lens of convergence: ‘where systems of race, gender and class domination converge’ (Crenshaw 1989). The strength of this intersectional approach lies in its ability to highlight the ‘structural, political and representational realities’ (Mackinnon  2013) that reinforce disadvantage and vulnerability. Hankivsky (2012) applies these concepts of intersectionality to deepen our understanding of health (women’s health, men’s health, gender and health) and highlight the limitations of using gender (and/or sex) as a single explanatory axis. In other words, to truly understand the impact of social stratification on health outcomes, it is necessary to investigate multiple factors, not the single dimension of sex/gender alone. Taking an intersectional lens to public health policies and programmes to increase our understanding the axes of power and, conversely, axes of marginalisation and inequity, allows us to identify those groups in society who may be vulnerable to risk and illness not only on the basis of gender, but also within a framework of overlapping inequalities and disadvantages. For example, patterns of tobacco consumption follow not only gender divisions within society, but also social class and education gradients. Furthermore, the gendered distribution of tobacco smoking is influenced by the level of economic development of society as a whole and the geographical locales where patterns of tobacco smoking are first established in any society. In western Europe, for example, there has been a fifty-year shift in tobacco smoking from men to women and from higher to lower social classes (Thun  2009). This shift influences both current smoking rates and quit rates (Graham 1998; Helmert et al. 1999). These effects are mediated by education level—with a positive association between low income, poor educational attainment, and smoking initiation (Voorhees et al. 2002). As a result, in some European countries the highest rates of smoking uptake are now seen amongst girls from disadvantaged social groups (Currie et al. 2008). In India, studies find a clear relationship amongst age, socio-economic status, gender, and tobacco use (smoking or chewing): men who are less educated, poorer, rural, and lower caste have higher rates of smoking and chewing tobacco than higher educated, richer, urban, higher caste men. Conversely, urbanisation is associated with higher rates of smoking tobacco in women, although the extent of smoking in women may be lower than predicted by models from other countries, possibly because ‘smoking remains a  taboo amongst [Indian] women . . . [with] moralistic connotations’; that is, gender norms are directly influencing smoking rates (Bhan et al. 2012).

Gender and Health Behaviours The health behaviours include those behaviours that expose people to risk of ill health as well as those that are associated with protection, care-seeking, and treatment compliance. Amongst the major risk behaviours that drive the highest burdens of ill health globally, tobacco smoking and alcohol consumption stand out as showing clear relationships

242   Sarah Hawkes and Kent Buse with gender norms—and both behaviours drive a significant proportion of the health gaps seen between men and women in many countries (Trovato and Lalu 1996; Pampel 2002; Bobak 2003; Pampel 2005; Janssen and Poppel 2015). For example, Beltrán-Sánchez (2015) and colleagues, reporting from their analysis of cohort data sets in high-income countries, found that the rate of mortality decline in the nineteenth and twentieth centuries was 70 percent faster for women than men. As much as 30 percent of the excess male mortality was calculated as being attributable to smoking tobacco, with its consequent impact on risk for heart disease, stroke, and cancer. For Courtenay (2000) and Wilsnack, Wilsnack, and Obot (2005), both tobacco and alcohol are intimately tied up with gender norms that equate risk-taking behaviours with positive aspects of masculinity—a norm that is perpetuated and exploited through the actions of commercial companies that seek to use gender as a device for market segmentation and success (Hawkes et al. 2018). Gendered expectations of occupation drive differences in risk exposure in a third major area: road traffic accidents. It is estimated that three-quarters of the 1.2 million deaths per year on the road are of men (frequently young men) (Sengoelge et al. 2018), in part due to higher rates of exposure, as men are more likely to be drivers, including in transport-related occupations, and possibly due to gender-related attitudes towards driving (Bergdahl 2007) and speed. However, gender, as previously noted, is not static and is subject to manipulation and change. In the United Kingdom, for example, age cohort studies on populations born in the 1930s, 1950s, and 1970s found different relationships between masculinity/femininity and smoking prevalence in men and women from each of the cohorts, reflecting changing gender roles across wider society (Hunt et al. 2004). Meta-analysis of alcohol-associated harms analysed across sixty-eight studies found a significant reduction in the differences in patterns of alcohol consumption, problematic alcohol use, and health harms due to alcohol between men and women born at the beginning of the twentieth century compared to those born in the closing decades of the century (the gap decreased from 2:1 to 1.1:1 (male:female) for alcohol consumption, 3:1 to 1.2:1 for problematic alcohol use, and 4:1 to 1.3:1 for health harms) (Slade et al. 2016). This so-called gender roles modernisation hypothesis (Waldron 1997) has been used to explain the shift to previously male-dominated behaviours when girls and women gain autonomy (including financial autonomy) and agency. Tobacco and alcohol companies have exploited this gender norm shift for many years—tobacco companies called cigarettes marketed at women ‘torches of freedom’ as far back as the 1920s (Amos and Haglund  2000)—and in public perception tobacco has been closely associated with fashion, body image (slim women), and emancipation. Tobacco companies (and increasingly, alcohol companies) looking for new markets are currently ‘capitalising on social and economic change’ in both Africa and Asia to market cigarettes to young women (Gilmore et al.  2015). Such tactics appear to have worked in recent decades across Europe. Studies of smoking and alcohol use amongst girls and boys aged 15–16 years across thirty-five European countries found that the gender gap in reported tobacco smoking rates amongst adolescent boys and girls disappeared between 1995 and 2007 (Hibbell et al. 2009), and both sexes reported similar rates of drunkenness in the

Politics of Gender and Global Health   243 recent past (‘intoxication to the point of staggering when walking, having slurred speech or throwing up’). Gendered occupational structures, mediated by class, education, race, and so on, contribute to differences in risk exposure. In simplest terms, men and women suffer different rates of exposure in the workplace according to location (inside the domestic sphere or outside within the paid workforce), occupation, and position. Whilst men, for example, are more likely to be working outside the home in positions of secure formal employment and have greater access to economic resources as a result, they are also more likely to be involved in workplace accidents, injuries, and fatalities (Stergiou-Kita et al. 2016). Indeed, data from the GBD show an almost seven-fold higher rate of occupation-related deaths amongst men than amongst women globally (Lim et al.  2013). Conversely, women are more likely to face work-related exposures in both domestic and paid work. However, given that women work more frequently in the informal sector than do men, both in paid employment and at home, women’s work is less likely to be covered by mandatory workplace reporting systems or legislation to cover their occupational health, thus potentially leading to under-reporting of women’s occupation-related risks (Messing et al. 2003; Messing and Ostlin 2006). Gender also impacts participation in activities that can lead to reductions in health risks. For example, studies have suggested that differences in patterns of physical exercise between men and women can be accounted for by girls’ lower enrolment in organised sport clubs (Vilhjalmsson and Kristjansdottir 2003), which, in turn is influenced by gendered roles and stereotypes (Chalabaev et al. 2013) as well as concerns about body image (Slater and Tiggemann, 2011). Beyond the level of individual (gender-influenced) decision-making, research on urban planning and the use of public space (e.g., for walking or exercising) has noted gendered differences in the experience of and engagement with city spaces, frequently resulting in a restriction of women’s full enjoyment of urban spaces (Beebeejaun 2017), with its attendant impacts on rates of physical activity and active mobility (EURO 2016). Gender plays a significant role in determining how, when, and where people seek healthcare. Gender inequalities may limit the access of women and girls to health services. For example, when healthcare is associated with out-of-pocket payments, women’s lack of autonomy and access to financial resources can act to restrict their use of health services (Saikia and Bora 2016). Further, privatisation of health systems, such as through expansion of private health insurance coverage, tends to lean towards women’s health needs being subject to additional fees. For example, private health insurers in Chile offered health plans to women of reproductive age that were ‘affordable’ but excluded coverage for maternity care (Ewig and Palmucci 2012). Studies also highlight that in patriarchal settings where resources are limited, young and infant girls are less likely to receive health services than boys, including preventive services. For example, studies in India have shown that girls are less likely than boys to be seen in outpatient services or to be admitted as inpatients (Khera et al. 2014). Although generally women have higher patterns of health service utilisation than men, much of this is associated with their reproductive health needs. In some settings,

244   Sarah Hawkes and Kent Buse even after adjusting for reproductive health consultations, women still tend to use health services more than men—including for screening checks and preventive health services. Studies in the United Kingdom, for example, show that those least likely to attend preventive cardiovascular checks were men who were on low incomes, had lower socioeconomic status, were unemployed, or were less well educated (Dryden et al. 2012). Why are men less likely to use health services? Courtenay has examined the role that gender norms and normative assumptions around masculinity play in this. He characterises these norms as driving a ‘better to die than cry’ position (Courtenay 1999). Studies in the United Kingdom of the relationship amongst ethnicity, gender, and care-seeking amongst men with a confirmed diagnosis of a myocardial infarction or angina found that projecting a high threshold for pain and discomfort was seen as a positive attribute of masculine behaviour, particularly amongst white men (Galdas et al. 2007). Conversely, there is some evidence that men’s decisions to consult health services are predicated on positioning themselves as ‘legitimate’ users of healthcare in contradistinction to ‘frequent and trivial users of health care’ (Noone and Stephens 2008). Others have used this explanation to seek to reposition help-seeking within the discourse of masculinity, as a means of taking control and responsibility, that is, a masculine act (Farrimond 2012; Galdas et al. 2005, 2007, 2010).

Gendered Institutions Health (and other) systems are gendered in terms of who receives quality care (and for what conditions), in terms of who is providing the care, and in terms of the focus of health research. The structure of health systems in terms of ‘insurance systems, fees, the range of services offered, patient healthcare incentives, and work structures and regulations’ matters for gender equality, gender equity, and health equity (Ewig 2016). Gender is embedded in the politics of health systems through decisions about financing (including through processes of commercialisation and privatisation) (Mackintosh and Koivusalo, 2005), priority-setting (decisions to focus on or exclude conditions, diseases, and illness burdens that bear differential impacts across society), service delivery (the gendered nature of services that are inaccessible on account of working hours or geographical location), and the quality of care delivered. As noted previously, when health systems require payment at the point of care or are reliant upon insurance schemes, women tend to have reduced access to services. Evidence from India, Nigeria, Tanzania, and Colombia finds that women persistently reduce their healthcare-seeking patterns as they have less access to financial resources, with the greatest impact being suffered by women in poorer and female-headed households, women in rural areas, and women with additional care-seeking responsibilities (for children or the elderly). Furthermore, such women, when they do seek healthcare, have disproportionately higher levels of out-of-pocket and catastrophic health expenditures (Brinda et al. 2014; Onah and Govender 2014; Amaya-Lara 2016; Saikia, Moradhvaj, and Bora 2016).

Politics of Gender and Global Health   245 In the United States, women have been found to incur higher expenditures in accessing both health and social care (Kaiser Family Foundation 2016; Williams et al. 2017). The politics of providing free at the point of demand health services can result in a reduction of these gender-derived differences in service use and associated financial impacts. A study conducted in the United Kingdom (where healthcare is, in the main, universally accessible and free at the point of delivery) by Wang and colleagues (2014) looked at gendered differences in consulting patterns amongst over twelve thousand patients aged 16 years or over diagnosed with colorectal cancer, over eleven thousand patients with lung cancer, and over four thousand patients with malignant melanoma. They found little evidence of differences between men and women in numbers of consultations and the number of general practitioner contacts made within twenty-four months prior to diagnosis. An in-depth qualitative investigation of twenty-seven men and eighteen women responding to symptoms later diagnosed as lung cancer revealed more similarities than differences between men’s and women’s accounts, notably a common moral about stoicism in response to symptoms and responsible service use (MacLean et al. 2017). In addition, a systematic review of consultation for back pain and headache, for example, found surprisingly weak and inconsistent evidence of gendered differences (Hunt et al. 2011). There is a growing body of evidence to show that whilst women may overall be more likely to access health services, and more likely to be providers of healthcare, they are less likely to receive quality care and effective treatment across a range of conditions (Arber 2006). In Sweden, for example, men receiving outpatient care for different skin conditions were more likely than women to receive intensive treatment options (Osika et al. 2005). Differences are particularly pernicious in the case of care for cardiovascular disease (CVD). Amongst patients with CVD in the United States, women were noted to  receive poorer quality care and have worse clinical outcomes—particularly seen amongst women of ‘diverse race and ethnicity’ (Shaw et al. 2017). Shaw and others have attributed this to women being less likely to receive evidence-based therapies, to have symptom-guided procedures, and to receive cardiac rehabilitation or life-style recommendations than men (Radovanovic et al. 2007). Within health and medical research, women have frequently been omitted from studies and research populations—a phenomenon that has been attributed to the male bias in what is considered ‘normal’. From Aristotle’s observation that ‘the female is, as it were, a mutilated male’ (Mayhew 2004) through to medical textbooks that are dominated by descriptions of male bodies (Lawrence and Bendixen 1992), understanding the male experience has been considered the norm for much of medical and clinical research. For example, guidelines for treating cardiovascular disease are predominantly based on trials in men, but the clinical presentation and symptoms of cardiovascular disease can be different between men and women (Maas et al. 2011). It has been argued that as a result, women are more likely to receive a wrong diagnosis, suffer from missed opportunities for intervention, or receive drug dosages that are inappropriate for their biology and physiology (Hawkes et al. 2019).

246   Sarah Hawkes and Kent Buse

The Gendered Health Workforce Globally, it is estimated that over 70 percent of the health workforce is female, but 70 percent of the leadership (and 80 percent of board chairs) is male (Global Health 50/50 2018, 2019). A recent review by the WHO Global Health Workforce Network’s Gender Equity Hub (2019) highlighted four areas contributing to gender inequity and gender inequality in the global health workforce: occupational segregation (e.g., gender norms mitigating against men becoming nurses), (dis)respectful workplaces (bias, discrimination, and harassment common in the health system, and women less likely to belong to trade unions), inequalities in power (women less likely to be in positions of leadership), and inequalities in pay (reinforced by women occupying lower status positions). Additionally, women, compared to men, in the health and social care sectors (Newman 2014) are more likely to be engaged in unpaid labour (e.g., as community health workers Kasteng et al. 2016), have lower access to training and professional development (Churnrurtai et al. 2007), and report a generally lower quality of life (Kheiraoui et al. 2012). A review of 198 organisations active in and with an interest in global health found that whilst 70 percent of organisations had a public commitment to gender equality in the workforce, less than half had any policies, strategies, or targets to achieve such equality (Global Health 50/50, 2019). The report also found that those workplace policies that underpin both gender equality and diverse, inclusive, and respectful workplaces were either not publicly available (e.g., only one-third of organisations have their sexual harassment policies online) or did not meet global norms (fewer than one-third of policies evaluated met best practise standards for a comprehensive sexual harassment policy). In short, whilst gender equality may be an aspirational commitment for many organisations active in the global health sector, the reality is that most of the same organisations are operating without the necessary policies and practises to support a more gender-equal workforce in a non-discriminatory and respectful working environment. In summary, gender, experienced through unequal expectations, opportunities, and responsibilities, impacts how long each of us can expect to live and our risks of ill health. Gendered actions drive not only our exposure to health-reducing products, environments, and circumstances, but impacts on whether or not we are likely to seek care or health services. Moreover, gender determines who is likely to be running the health system (men), who will provide us with ongoing care in hospital or at home (women), and how much or whether or not people get paid for providing such care. Despite this strong and compelling body of evidence highlighting the relationship between gender and health and gender and career progression, reviews of organisations that have an influence or interest in global health, find that they are predominantly ‘gender blind’—that is, they fail to take gender into account in their policies, programmes, and services (Amos et al. 2012; Hawkes and Buse 2013; Hawkes et al. 2017; Global Health 50/50, 2018). In the next section we explore in more detail the politics of gender blindness through a review of the history of gender as a concept in global health and an exploration of the roles that power and patriarchy play in determining agendas, discourse, and responsiveness.

Politics of Gender and Global Health   247

Gender and Global Health: Reviewing Organisational Responses Within the realm of global health, ‘gender’ is frequently understood and measured as differences between the health experiences of ‘men and women’. The political nature of why and how those differences arise, how organisations respond, and who is the target of policies and programmes to redress remediable gaps is less frequently discussed in global health. Notions of gender equity and gender equality are crucial to understanding the political nature of how global health institutions have responded to observed differences in the health and well-being of people of all genders. Concepts of social justice date back centuries in philosophical, political, and economic traditions and apply to both individuals and institutions. Rawls’s (1971) emphasis on the role of social institutions in the (just) distribution of social benefits carries direct implications for how global health organisations and institutions determine who shall accrue the ­benefits of health policies and programmes today. Jaggar (2014) emphasises that those working on questions of ‘gender global justice’ are frequently assumed to be working on a narrow range of issues of relevance to women—‘female seclusion, genital cutting, religiously based systems of law . . . and sex trafficking’. She also emphasises, however, that all issues of global justice have a gender dimension—including health and global governance (Jaggar 2014, 9). Within global health organisations, the emphasis on justice in relation to gender and health (and associated distribution of benefits) has tended to be limited to narrow definitions of gender inequality adversely affecting the health and well-being of women and girls. Notions of the universality of gender justice within ­global health have tended to be lacking. Gender equality was established as a universal principle at the birth of the modern multilateral system over seventy years ago, and the United Nations (UN) agencies were the first proponents of a gender discourse in the global health arena. In 1946 the UN Economic and Social Council established the Commission on the Status of Women, a body that continues to the present day. When WHO was established in 1948 it committed to realising the right to health of ‘all peoples’ but gave a particular emphasis to maternal and child health as one of twenty-five core activities (WHO 1948), thus setting the stage for future directions of gender equality in health with implications for resource allocation and policy direction. At the end of the UN Decade for Women (1976–1985), WHO, under the direction of Director-General Halfdan Mahler, published a report on women, health, and development that emphasised ‘protection of women’s physical and mental health . . . and . . . assist[ing] women to carry out their function as providers of primary health care’ (WHO 1985). Whilst the report emphasised women’s particular health needs, it also reasserted that ‘the overall health needs of men and women are the same in this regard [environments hazardous to health]’ and recognised the changing nature of health problems faced by the changing nature of societies: ‘Men are at greater risk than women for a number

248   Sarah Hawkes and Kent Buse of  health problems often associated with their work and with changing lifestyles or stress—such as accidents, lung cancer, alcoholism, and cardiovascular diseases. However, women’s changing lifestyles may soon place them at equal risk for stress- and lifestyle-related problems’. Nonetheless, the report stated that ‘[w]omen’s special health needs are primarily related to their reproductive role’. The first inclusion of ‘gender’ as an issue in the global health arena came in 1993 when the Tropical Diseases Research (TDR) programme of WHO published ‘Gender and Tropical Disease: Research to Lift Women’s Burden’ (WHO 1993); the following year ‘gender’ entered the health and development lexicon more widely when the International Conference on Population and Development (ICPD) noted, ‘Advancing gender equality and equity and the empowerment of women, and the elimination of all kinds of violence against women, and ensuring women’s ability to control their own fertility, are cornerstones of population and development-related programmes’ (ICPD PoA, 1994). From the earliest days a discourse around gender and health arose that conflated gender with women’s health, and in particular their reproductive health. This conflation has continued through both the Millennium Development Goals (MDG 3, Promote gender equality and empower women, and MDG 5, Improve maternal health) and into the 2015 sustainable development goals (SDG 5, Achieve gender equality and empower all women and girls, and SDG 3, Ensure healthy lives and promote well-being for all at all ages, with its first target being a reduction in the maternal mortality ratio). Over the past few decades there has been no dearth of policies, guidelines, strategies, and tools developed by the multilateral system, development partners, and national governments to make health systems more gender responsive. Frequently this has been undertaken through a lens of gender mainstreaming—a strategy aiming to institutionalise gender equality within systems, including health systems. True and Mintrom (2001) argue that transnational networks, predominantly of women’s non-governmental organisations (NGOs) in collaboration with agencies of the United Nations, have played a significant role in the diffusion of the ideas (and policies) of gender mainstreaming globally. Possibly as a result of the actors involved in the push for gender equality (i.e., the feminist advocacy and activist movements, which took global shape in the 1970s and 1980s; Jaggar 2014), the focus of much of gender mainstreaming, including in global health, is on improving health outcomes for women and girls (Smith et al. 2016; Hawkes et al. 2017). Whilst this is understandable in terms of the inequalities of patriarchy, there are those who are concerned that the particular focus of much medical attention is driven by ‘biological reductionism’. This results in women being seen in health policies, programmes, and research as people ‘whose “health” (and that of their children) is determined by their ability to become pregnant, give birth, and adequately mother their offspring’ (Inhorn and Whittle 2001), Whilst the underlying principles of universality of healthcare are enshrined in human rights principles (and law), the experience of the past several decades suggests that ­global health organisations selectively focus on segmented population groups rather than the entire population (Seeley and Allison 2005). In the main, and as shown through the stated areas of concern for 198 organisations active in global health (Global Health

Politics of Gender and Global Health   249 50/50, 2019), the result is that the health needs of women and girls (and particularly their reproductive health needs) receive more attention than the health needs of men and boys. Moreover, the work of Global Health 50/50 has shown that even when organisations do focus on the health needs of women and girls, they frequently do so without mention of the terminology ‘gender’. There have been moments of inclusivity in the discourse of global health, but to date these moments have not proven to be sustainable. For example, the Alma Ata declaration of 1978 was promoted as ‘Health for All’, and many human rights declarations and treaties have underscored that the right to health (including the right to healthcare) is universal (WHO 1978). Nonetheless, shortly after Alma Ata the global health academic and funding communities raised questions of prioritisation on the grounds of economic affordability. In their highly influential paper published just one year after the Alma Ata conference, Walsh and Warren called for ‘selective’ primary healthcare whose ‘principal recipients . . . would be children up to three years old and women in the childbearing years’ (Walsh and Warren 1979). The ‘success’ of this selective approach is seen today in many countries where the primary healthcare system is often synonymous with provision of services for maternal and child health and family planning (Vlassoff et al. 2010).

The Gender Agenda of Global Health: Current Responses Organisations with an interest and influence in global health (OGHs) include a broad range of intergovernmental organisations (IOs), development partners, funders and foundations, public-private partnerships, and private (for-profit) entities with an interest in global health. In our approach to understanding how OGHs address gender in their work, we draw upon findings from ongoing analyses as well as previous studies of how these organisations have mainstreamed (or not) gender into their policies and practises. OGHs represent major stakeholders in global health and often have power and influence over national health policy. The institutional positions that OGHs pursue with regards to gender have implications for their role and influence in normative guidance as well as their decisions about what (and who) to fund. The global public-private partnerships for health, for example, are powerful actors in global health decision-making, with two alone (the Global Fund for AIDS, TB and Malaria, and GAVI) accounting for over 12 percent of all external funding to the health sector globally (IHME 2018). The OGHs have been shown to be significant stakeholders in setting and sustaining global health agendas (Shiffman and Smith 2007), including the attention paid by global and national political (and health) leaders to specific health issues, as well as decisions about resource allocation. Therefore, the position that these organisations take vis-à-vis complex issues such as gender (or poverty, race, or other dimensions of inequality) carry far-reaching implications in terms of how issues are framed and what gets funded.

250   Sarah Hawkes and Kent Buse As noted, our review of 198 OGHs involved in norm-setting and funding at both global and national levels found that two-thirds of the organisations gave no definition of gender, and if they did define what they meant by gender, in over 90 percent of cases this did not include recognition of non-binary identities (Global Health 50/50, 2019). The lack of a clear definition and understanding of gender in many OGHs means that they have generally been slow to respond either to the changing nature of women’s risk-taking in many parts of the world or to evidence of men’s disproportionate risks for some of the major global health problems (non-communicable diseases, violence and injury, etc.). Despite ‘gender mainstreaming’, the approach to gender, particularly amongst the development-based organisations, has been characterised as ‘simplification, sloganising and lowest common denominator consensus’ (Cornwall et al. 2007). In their review of gender in the policies and practises of international development, Cornwall et al. (2007) challenge the frequent portrayal of women and girls as ‘both heroines and victims: heroic in their capacities for struggle, in the stead-fastness with which they carry the burdens of gender disadvantage and in their exercise of autonomy; victims as those with curtailed choices, a triple work burden and on the receiving end of male oppression and violence’. This oversimplification, they note, might ‘have the power to move’ but is ‘very far from the complexity of women’s and men’s lives’. The ‘vulnerable victim’ nature of much global health discourse around women and health serves to overlook the evidence of a number of fundamental relationships between gender norms and health outcomes that are currently being poorly addressed by the global health community. In this chapter we have shown, for example, that not only do boys and men suffer poor health outcomes across all age ranges, but they frequently do not access public sector (or development partner–funded) health (treatment or prevention) services. Furthermore, men’s rates of risk exposure to major drivers of morbidity and mortality frequently exceed those of their female peers. As a result, men’s life expectancies are curtailed relative to women’s in every country in the world. Cautioning against framing these issues either with men as a ‘public health problem’ or ‘men as victims of male roles’, Smith et al. (2016) propose that instead public health practitioners and scholars should focus on the social, economic, and political contexts that shape men’s experiences of their own health trajectories. In other words, we should frame men’s experiences of health, well-being, and illness in the realms of gender as a social determinant of outcomes and address these determinants rather than focus solely on attempting to change individual men themselves. Alongside this, the predominant focus on women as ‘reproducers’ (Inhorn and Whittle 2001), with the associated public policy focus on pregnancy, childbirth, and the survival of young children, has resulted in the health concerns of the majority of women being overlooked; programmes focusing on women’s risks from the major killers (diabetes, cancer, heart disease, and lung disease) are notable by their absence from much of the global health discourse. Moreover, the changing nature of gender norms in much of the world might have been seized upon by the commercial sector keen to see sales of tobacco, alcohol, and fast food increase amongst young women (the so-far ‘untapped market’), but the global health community has been slower to see young women’s

Politics of Gender and Global Health   251 gendered health needs as much beyond their access to family planning and safer sex interventions, let alone to recognise the gendered nature of men’s poor health status. In the remainder of this chapter we examine several factors that may have contributed to both the absence of a full understanding and the attention paid to gender as a determinant of shared health and well-being outcomes globally, then consider the changes that need to happen to bring about a truly gender-responsive global health system.

Gender and Health: The Absence of an Effective Response What has driven the global health community to either ignore the evidence on gender and health or to selectively choose to focus on the health needs of only some of the population (usually women and girls)? There is likely a range of factors that have led to gender (in its true definition as a social construction that drives health and well-being outcomes for everybody) not being high on the agendas of global health actors. A contested terminology: In many parts of the world the ‘gender question’ continues to be subject to furious political, philosophical, and religious debate—including in those countries where the term ‘gender’ simply does not exist in either cultural or linguistic spheres. The results of this discord around the discourse and meaning of gender can be seen in the political sphere, where governments withdraw public funding to university departments that work on gender (Reuters 2018), or work to remove the very term gender from global discourse (Borger 2018). Within gender studies, however, the term has frequently been collapsed to mean ‘women (and girls)’. Connell (2014) suggests that this is a reaction against the history of ‘knowledge [which] has traditionally been constructed from men’s point of view’. When feminists rose to positions to challenge the existing patriarchy, they focused on reasserting women’s experiences, ‘lives[,] . . . perspectives and knowledge’ into culture (Connell 2014). The outcome of this endeavour to ‘re-feminise’ previously male-dominated spaces can be seen in the proliferation of health organisations that focus on women and girls. A blame game: The ‘gender paradox’ in health highlights the inequalities in experiences of morbidity and mortality between men and women. In short, men die younger but women suffer more ill health (Read and Gorman 2010; Bastos et al. 2015). This lower life expectancy of men is frequently described as a result of ‘toxic masculinity’—whereby men’s risks, exposures, and experiences resulting in poor health outcomes are individualised to notions of men’s poor choices and poor behaviours, rather than as a recognition of the social, structural, and commercial determinants driving their health status (Smith et al. 2016; Fisseha and Hildebrand 2018). Fractured policy and epistemic communities: Within the health sector, the absence of a cohesive policy or epistemic community (i.e., actors ‘responsible for developing and circulating causal ideas and associated normative beliefs’; Haas 2008) focused on gender

252   Sarah Hawkes and Kent Buse may have played a role in slowing progress to make global health more gender responsive than it currently is. The lack of a shared understanding of gender as a determinant of health and well-being across the whole population can be seen in the proliferation of policies, programmes, and research activity that focus on the health of one part of the population but rarely address health as a gendered determinant for everyone. Whilst many countries have health strategies to address the health needs of women and girls, only four countries (Australia, Brazil, Iran, and Ireland) also have health strategies for men and boys. And whilst WHO first produced a health strategy for women in 1985, it was only in 2018 that one of the regional offices produced a report on the health and well-being of men (EURO  2018). There are no examples (as far as we are aware) of national (or global) health policies that address gender as a health issue for all people. Health programmes at global, national, and subnational levels frequently respond to the health needs of women and girls (and may even apply a gender lens to responding to their needs), but in our review of 140 OGHs, we were unable to find a single global health NGO working in at least three countries and focusing only on the health of men and boys (Global Health 50/50 2018). The tendency to split the health community along binary lines—segmenting health into the needs of women or men, girls or boys—rather than addressing shared determinants and shared responses acts to continue to place gender as an issue of interest to half the population only. Within academic communities, gender studies are frequently led by people focused on women’s studies in a range of disciplines, such as history, sociology, politics, and cultural studies (Connell  2014). Promoting ‘men’s studies’, however, is seen by Connell as risking the creation of a ‘vehicle for masculine backlash’. Much research on ‘gender’ therefore continues to focus on the lived experiences and unequal positional power of women and girls, perhaps out of concern that expansion to include men and boys (and transgender populations) may result in a ‘backlash’. Institutional path dependency: Organisational change towards more gender-responsive global health is rare—in part because it requires agreement on ideas (and terminology), addressing organisational interests, and tackling institutional (in)ability to change. Institutional path dependency is a key force in the behaviour of OGHs (Gomez and Atun 2013) and may help explain the absence of institutional change or gender-responsive reform, despite the overwhelming empirical and social constructionist evidence of the role that gender plays as a shared determinant of everyone’s health.

Conclusion In this chapter we have highlighted the relative ‘gender-blindness’ of many organisations active in global health and have contrasted that with the body of empirical evidence that highlights the importance of gender both as a determinant of outcomes of health and well-being and as an indicator of career progression within the health sector. Whilst gender rarely acts alone (but instead intersects with other social stratifiers of powerlessness

Politics of Gender and Global Health   253 and disadvantage), it is nonetheless one of the most important global determinants of life chances, life course health status, and life expectancy. Given that gender is a socially constructed phenomenon, it is mutable, flexible, and amenable to policies, programmes, and practises that seek to change it. Despite this, much of global health remains resolutely gender blind or continues to be gender selective, with a focus on women and girls and little (or no) consideration given to the relational aspects of gender and its impact on everyone in society. Sex-disaggregated data on the burden of disease show differences between burdens suffered by men and those suffered by women in all countries. In general, men’s life expectancies are shorter than those of women, but women live for more years in ill health. These differences tend to be smaller in the poorest countries, but in some countries (e.g., in eastern Europe), differences in life expectancy can be over ten years (Kyu et al. 2018). As noted in this chapter, as societies become economically richer and women become more empowered, there is evidence that for some conditions (particularly those associated with the consumption of alcohol and tobacco, two of the most important contributors to ill health and premature death in the world), the gap between men and women may narrow, predominantly due to changes in women’s behaviours over time. These gender-related social phenomena have been noted and exploited by commercial companies but have tended to remain beyond the focus and attention of public health communities. Instead, as noted in this chapter, global and public health communities have historically focused their attention and resources on the health of women and girls (Global Health 50/50 2018; Hawkes and Buse 2013). ‘Gender’ as an idea and a term has only been common currency in global health since the mid-1990s, but although gender refers to norms, behaviours, attributes, expectations, laws, customs, and so on that impact the socially constructed identity of what it means to be male/female/non-binary in any and every society, the notion of gender as a determinant of health inequities amongst all people has not been successfully integrated into public health programmes to improve the health of everyone in the population. In this chapter we have argued that despite the acknowledgement of the universality of the right to health and widely known evidence of the sex-disaggregated distribution of risks and disease, global health programmes have tended to focus on a specific set of needs of some of the population—namely women and girls. Whilst global agreements since the 1940s have declared both health and gender equality as universal human rights, the prevailing politics and power of resource allocation, including in development cooperation for health, have tended to see the realisation of these rights favouring men in terms of gender equality and women in terms of health and life expectancy outcomes. Integrating gender equality within global health has frequently been collapsed simply to mean the delivery of programmes focusing on reproductive, maternal, and child health. Integrating a gender perspective to benefit the health of the whole population has not yet been widely adopted across the global health community, and one reason for this may be the absence of communities and networks of gender advocates concerned with gender as a determinant of everyone’s health. In addition, the contested terminology of

254   Sarah Hawkes and Kent Buse gender and the institutional path dependency of GHOs has resulted in a widespread ‘gender blindness’ within global health. Redressing this to promote gender-responsive policies and programmes is likely to require an overtly political approach. In much the same way that interest group and organisational power has kept gender off many agendas or manipulated its meaning, an understanding of power will be needed to make global health gender responsive. It is likely that the power of a strategic multi-actor response such as an advocacy coalition (Sabatier and Jenkins-Smith 1993), encompassing the many faces and facets of the global health community and acting across multiple spheres of the health sector and the social, commercial, and political determinants of health outcomes, will be required to make health gender responsive. Rao-Gupta et al. (2019), for example, call for gender-responsive global health that focuses on health inequities, promotes gender-equitable workplaces, eliminates gender biases in research, and is both adequately funded and held to account through independent accountability mechanisms. Whilst this might appear an aspirational set of asks, our continuing gender-blindness will hinder our ability to make progress on a range of targets within the sustainable development agenda. It is time for the global health community to embrace gender responsiveness and recognise that gender equality and health equity are everyone’s responsibility.

Acknowledgements With thanks to Dr. Erica Nelson for work on the history of gender within global health, and Dr.  Elias Nosrati for evidence on the relationship between gender and non-communicable diseases.

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pa rt I I I

GL OBA L H E A LT H G OV E R NA NC E

chapter 14

Gl oba l H e a lth G ov er na nce Colin M c Innes

In March 2014 hospital staff in the West African country of Guinea identified unusual cases of a fatal disease in the southeast of the country. Over the remainder of the year the outbreak—identified as Ebola Virus Disease—became a stark test of the global health governance (GHG) system. In June 2014 the non-governmental organization (NGO) Medecins sans Frontieres/Doctors without Borders (MSF) warned that the outbreak had become ‘out of control’ (MSF 2014), whilst later in the year the US Centers for Disease Control and Prevention (CDC) produced a worst-case scenario of over 1.4 million cases in Sierra Leone and Liberia by January 2015 (CDC 2014). With cases diagnosed in Europe and North America during mid-2014, albeit in very small numbers but receiving high publicity, and with established methods of control appearing to be failing in West Africa, world leaders queued up to express their concern. Crucially, in relation to this chapter, their concern was not solely for the tens of thousands estimated to be at risk from the disease in West Africa, nor over the risk to their own citizens from the outbreak, but about the system of GHG more generally, which appeared to be failing (though see Kamradt-Scott 2016 for a counter to this point). In particular the World Health Organization (WHO)—the United Nations’ (UN) ‘directing and coordinating body’ for international health cooperation, and historically the main source for international guidelines and regulations to protect and promote health—received widespread and sustained criticism for its performance, leading to renewed calls for its reform and even replacement (e.g., Gale and Lauerman 2014; New York Times 2015; Nebehay 2014; Moore 2014; Clift 2014; Heyman et al. 2015, 1884–1901). Critics blamed poor leadership and weak management, both at WHO headquarters in Geneva and at its African Regional Office (e.g., Nebehay 2014; Miles 2015; House of Commons 2014; Beaubien 2015; KamradtScott 2016; Stocking 2015, 18). Criticism also identified organisational failings, a view reflected in the “Stocking Report,” commissioned by WHO’s Director General, on its handling of the outbreak (Stocking 2015; see also Kickbusch 2015; Clift 2014). For others, the Ebola outbreak revealed wider failings in GHG, up to and including the structural

266   Colin McInnes imperatives of neo-liberal market capitalism privileging profit over health needs (Fidler 2015; Gostin and Friedman 2015; Gill and Benatar 2016b; Kamradt-Scott 2016). The system of international cooperation for health is not new. International health regulations date back centuries, and the process of standardising them began with the first of fourteen International Sanitary Conferences (Youde 2012, 14–17). But since the establishment of WHO in 1948 there has been a proliferation of governance activities, many of which originated with that organisation. These range from declarations, to best practice guides, to conventions, to norms and moral codes. This proliferation of ‘soft laws’ in effect created a governance regime for global health. The regulations and other governance mechanisms, however, were largely of either a technical nature (e.g., vaccine delivery, disease notification, marketing of health-related products) or normative (e.g., 1978 Declaration of Alma Ata on Primary Health Care), rather than legally binding instruments. The 2014–2016 Ebola outbreak, however, is illustrative of the contemporary significance attached to GHG: the outbreak of a disease that had previously killed relatively small numbers , but which became a crisis in the fall of 2014 and which was subsequently estimated as potentially reaching 1.4 million cases in just two countries (CDC 2014), was blamed in no small part on failures in GHG. The outbreak also demonstrated how GHG—or rather, its failings—could become headline news and galvanise the international community into response. There is no small irony here, because what we have seen since around the turn of the millennium has been a growth in governance mechanisms and agencies involved in GHG. In particular, the study and practice of GHG has been transformed in two ways. First, the development of a new dominant discourse of ‘global health’ required a new way of thinking about governing health; after all, if health issues were the product of ­global processes, then it was a straightforward move to argue that health governance had to be global. This in turn had major political consequences in implying a shift in authority and power from national agencies to global institutions, as seen in debates over disease surveillance and the introduction of new global bodies for this purpose such as GOARN (the Global Outbreak Alert and Response Network), discussed later in this chapter. Second, the emergence of this new discourse coincided with, and on occasion led to, transformations in the ‘architecture’ of GHG—although GHG’s haphazard, unplanned evolution means that this architecture appears to be less the elegant functional simplicity of a neoclassical design, or even Gaudi’s organic (if somewhat fantastical) design for Sagrada Familia, and more Mervyn Peake’s bewilderingly complex and confusing Castle Gormenghast. This second transformation reflected both the growing significance of GHG and expectations that it could—indeed, should—lead to better health outcomes. But if the first transformation implied a shift in authority and power to the global, the second also implied a potential diffusion of authority and power at the global level, as the number of agencies proliferated, often with overlapping or competing mandates. This chapter therefore examines these two potentially competing transformations before discussing some of their political consequences for GHG, especially concerning the changed distribution of power (material and normative) and where authority is vested in global health.

Global Health Governance   267

The Transformed Discourse: From International to Global Health The cross-border dimensions of health have been widely recognised for many centuries. During the eighteenth and particularly the nineteenth centuries, the potentially detrimental impact of health on the burgeoning political and economic links between imperialist powers, and especially links within their expanding empires upon which their economic wealth and political strength were based, created a move for common regulations to prevent the spread of communicable diseases across borders (Youde 2012). This marked the birth of ‘international health’, which was more concerned with preserving the interests of imperial powers (e.g., in maintaining trade and their military capabilities) than with improving the health of local populations in colonised regions. In this way, the origins of international health reflected a power dynamic which, critics of global health suggest, remains today: international cooperation for health or GHG is more concerned with the interests of the powerful than with the needs of all. Although initially focused on the spread of communicable disease, international health evolved in the twentieth century to include the development of regulations and guidelines standardising protocols and best practices across a range of issues, from the development of new pharmaceuticals to ethical guidelines on the treatment of patients. During the 1990s, however, a shift in terminology from international to global health began to be apparent. This was concurrent with intense discussions in both the policy and academic worlds on the emergence and effects of globalisation and appeared to imply an ontological shift towards a more planet-wide rather than national view of health. Although there is a suspicion that for some this may have been simply a relabelling exercise, to give international health a more contemporary feel, the discursive act nevertheless created the space for a new meaning and a new politics to emerge. Tensions over globalisation were also reflected in global health. For its advocates, globalisation was not simply a macroeconomic process enabling further growth, but represented a new cosmopolitan politics in which responsibilities were shared across the globe and the powerful had obligations to help those in need if only out of enlightened self-interest. As British Prime Minister Tony Blair said in his era-defining 1999 speech in Chicago, ‘We cannot turn our backs on conflicts and the violation of human rights within other countries if we want still to be secure’ (Blair 1999). On the other side, critics of globalisation saw it as the latest iteration of imperialism, in which powerful economic and cultural actors imposed themselves on a planet-wide stage. Whereas some saw ‘global health’ as a recognition of common interests on a planetary scale requiring common solutions, others therefore saw it as a means of powerful actors shaping the health agenda on a planetary scale to fit their interests (see Schrecker in this volume). One of the most significant early examples of this discursive shift was a report from the (US) Institute of Medicine (1997), which set out ‘America’s vital interest in global health’ (see also Fidler and Drager 2009). Within a decade of this landmark publication,

268   Colin McInnes the discursive shift had been fully realised, such that in 2008 the United Kingdom was able to produce a cross-departmental policy statement entitled Health is Global, arguing that a purely national perspective on health policy was no longer adequate, given that health was now subject to global forces (Department of Health 2008). The reason for this shift was commonly ascribed to the material ‘fact’ of globalisation. In particular the potential for communicable diseases to spread more rapidly because of the increased speed and intensity of cross-border interactions was used as evidence for globalisation affecting health (see, e.g., Lee 2003). A much-cited example was the 2002–2003 severe acute respiratory syndrome (SARS) epidemic, which quickly spread across continents to cities as geographically distant as Hong Kong and Toronto. But SARS also demonstrated a more positive side of globalisation in the ability of the international scientific community to harness its collective talents to address the disease (Fidler 2004b; Kamradt-Scott 2015). WHO Director-General Gro Harlem Brundtland similarly located the impact of globalisation on the spread of disease, arguing that ‘[today] there are no health sanctuaries’; rather, humanity is ‘a single community within a common microbial sea’ (Brundtland 1999). But the impact of globalisation was also evident in other health issues, from the practices of large multinational food and drink companies (including ‘Big Tobacco’) popularising potentially harmful foodstuffs, to the global marketplace for pharmaceutical products, to the widespread use of antibiotics (not least in farming) leading to a global risk of antimicrobial resistance, to the relative ease with which health professionals could move across borders, to aid and development policies applying common principles across culturally diverse groups. Less frequently remarked upon, but nevertheless important for the politics of global health in that it affected where power and authority lay, was that globalisation was reconceptualising communities. In particular, commentators suggested that communities may no longer be bounded by national borders, but might be global in nature. Echoing Johan Galtung’s analysis from the 1980s, Gill and Benatar (2016a) suggested that what distinguishes health outcomes in a global community is not so much where you are but which social group you belong to (see also Schrecker in this volume). Thus the poor in the United States have more in common with the poor elsewhere in terms of health than they do with the rich in the United States. Others noted the growing emergence of a global civil society; that is, social movements with transnational perspectives and interests, usually seen as progressive forces or as key social mechanisms for giving voice to an individual’s political interests in a globalised polity (see, e.g., Lipschutz 1992; Falk 1995). In health terms, perhaps the most marked example of this was the emergence of transnational groupings lobbying for the rights of people living with HIV and AIDS (McCoy and Hilson 2009; Youde 2012, 99–114). The implication of this change in the nature of community is a change in the nature of the polity; political actors are no longer located within or by reference to nation-states, but rather by economic or social class or interests on a transnational or even planetary scale. As Jonathan Joseph has argued, however, globalisation can be seen not as a material fact but as a way of thinking about and explaining the world, which in turn allows it to

Global Health Governance   269 be presented as an unarguable fact to which there is no ‘common sense’ alternative (Joseph 2012, 86). In a similar vein, global health can be seen not only as a reflection of an exogenous material reality impacting health determinants and outcomes, but also as a social construction by powerful voices that gives meaning to this range of developments and creates a new form of social reality (e.g., McInnes and Lee 2012a). From this perspective, statements such as ‘health is global’ are therefore not simply a reflection of an external reality or even of a new rationality, but a call to reinterpret how we understand health and its determinants. Crucially, this rallying cry draws attention to health issues as being of renewed significance and to the fact that the meaning of health has changed. Health as global, in this sense, is normative in its framing or social construction of the subject; it is for someone and for some purpose, a force to change the world, not simply a reflection of an exogenous reality (see discussion in McInnes et al. 2014). The manner in which globalisation was presented by authoritative voices in the health community as an incontestable fact reflected the nature and location of power in the health community and allowed the mantra that ‘health is global’ to become one of the dominant narratives in contemporary health policy. This discursive shift, from international to global health, is vital in understanding the perceived challenges facing contemporary governance. If health determinants and outcomes are no longer the result of national actions, but rather of planetary-level forces (either material or ideational), then the requirement for effective global-level gov­ern­ance becomes more significant for the protection and promotion of human health. The narrative of ‘global health’, therefore, has led directly to calls for better GHG because of the perceived limits of national-level governance (see, e.g., Cooper, Kirton, and Schrecker 2009; Dodgson, Drager, and Lee 2002). David Fidler has gone further, arguing that WHO’s actions during the SARS outbreak, when it overrode the wishes of sovereign member states in issuing travel warnings, demonstrated its emergence as a body capable of supranational powers. For Fidler, this heralded a new ‘post-Westphalian’ era in health governance, in which states were no longer the supreme sovereign bodies (Fidler 2003, 2004a). However, the empirical evidence, not only for Fidler’s specific claim concerning WHO and SARS, but also for the wider argument of a developing shift from national to global health governance, is more equivocal (see, e.g., Kamradt-Scott 2015). Leach and Dry (2010), in contrast, identify the enduring importance of local practices and variations in healthcare, whilst Frank Smith (2010) persuasively argues that the response to the 2009 H1N1 ‘swine flu’ pandemic was informed by national interests rather than GHG. Others, however, focus less on whether a shift is occurring in where power and authority is located than on the weaknesses of the current system. Kickbusch and Reddy, for example, use the idea of governance ‘gridlock’ (from Hale, Held, and Young 2013) to suggest that the global health ‘system’ is unable to respond to challenges, though they also argue that gridlock can be overcome ‘when there is political pressure and the will for change’ (Kickbusch and Reddy 2015). System-level criticisms such as these, however, lead into the second key transformation, which concerns the structure and institutional architecture of GHG.

270   Colin McInnes

The Transformed Architecture of Global Health Governance If the narrative of global health changed expectations about governance and raised the potential for a shift in where power and authority were located, then the emergence of new global actors and networks has also changed not only the structure but also the expectations of GHG and where power and authority lie. These new bodies have generated a sense of opportunity: health can be improved through new methods, greater ­political attention, and/or increased capacity. But this opportunity has in turn been limited, both by the very proliferation of actors (creating a diffusion of authority) and by the often anarchic structure in which these actors operate. Some of these new actors arose directly because of the perceived need for better GHG—for example, organisations such as GOARN, which ‘pools human and technical resources for rapid identification, confirmation and response to [communicable disease] outbreaks of international importance’ (WHO, n.d.-a). Established in 2000 by WHO and partners, GOARN clearly reflected a sense that globalisation had changed the risk of communicable diseases spreading, requiring an improved, global capacity for surveillance and technical response (such as the identification of new viruses and development of pharmaceutical responses). Others are linked to the wider process of globalisation. For example, better global communications allowed the emergence of transnational networks such as the International AIDS Society, with members in over 180 countries. Yet others arose out of concerns at best tangentially related to globalisation or the need for better global gov­ern­ance. For example, the emergence of the Bill and Melinda Gates Foundation appears to have been prompted by humanitarian concerns. With an annual budget of US$1B (in contrast to WHO’s biennial budget of US$4B), the Gates Foundation has emerged as one of the most significant actors in global health in the new millennium, and whilst its motivations are rarely questioned, its lack of transparency and accountability, coupled with its ability to shape aid and policy agendas, have led to some concerns (see Youde in this volume). In contrast, state-led initiatives such as PEPFAR (the President’s Emergency Plan for AIDS Relief, launched by President George  W.  Bush) or the Global Fund to Fight AIDS, Tuberculosis and Malaria (hereafter Global Fund), although more transparent and accountable, nevertheless had more complex motivations linked both to humanitarianism and to the global effects of poor health (see, e.g., Dietrich 2007; Harman 2010). Five broad developments can be identified in this transformed landscape. First, and most common, is the increase in the number of actors and initiatives involved in global health, creating a complex and, for many, confusing institutional landscape. In 2011, for example, the Director-General of WHO, Margaret Chan, commented that there had been ‘truly stunning increases in the number of actors, agencies, and initiatives funding or implementing programmes for health development. The landscape of public health is crowded. Activities in some areas, in some countries, are frankly chaotic’ (Chan 2011). The increase led to accusations of policy incoherence, with gaps, overlaps, and even

Global Health Governance   271 competing and counterproductive agendas. Whilst increased resources for health ­development may be welcome, the demands of managing so many uncoordinated ini­ tiatives create a serious burden on governments and communities (Spicer and Walsh 2011). This is particularly apparent with ‘vertical’ programmes, which address single issues, and led Sophie Harman, in her study of the global response to HIV and AIDS, to make the stark assessment that ‘the governance of HIV/AIDS [sic] has come to represent a multi-faceted and complex operation that is not working’ (Harman 2010, 1). Second, not all of the actors are primarily concerned with health. Jeremy Youde, for example, has commented that the World Bank has become ‘the most important intergovernmental organisation working on global health issues’ and that it has ‘helped to remake how the international community interprets health’ (Youde 2012, 46), even though its primary concern is not health. These non-health-specific actors range across multiple policy sectors, including trade and security. In January 2000, for example, the UN Security Council became involved in health for the first time when it discussed HIV and AIDS, passing Resolution 1308 addressing the risk of HIV infection to peacekeepers; in 2014 it went further, identifying (in Resolution 2177) the West African Ebola outbreak as a threat to international peace and security. More controversially, the Doha Round of the World Trade Organization’s (WTO’s) negotiations proposed international protections for patents (Trade-Related Aspects of Intellectual Property Rights, TRIPS), which had a profound impact on the ability of third parties to provide cheap generic pharmaceuticals that poorer states could afford. Particular attention focused on an­ti­­ retro­vi­ral therapies (ARTs) for HIV and AIDS, given that those states that suffered the highest prevalence of the disease (largely in sub-Saharan Africa) were also amongst those least able to pay for these life-prolonging drugs. The third development concerns the rise of public-private partnerships. Williams and Rushton (2011) comment that perhaps the ‘most striking’ transformation in GHG has been the rise of private actors and their incorporation into what had previously been a public realm. In their critique of Kickbusch and Reddy’s argument that GHG is moving to a more multilateral system of governance, Gill and Benatar comment that ‘current frameworks of multilateralism are ultimately constituted and shaped by the fundamental economic and political structures, forces and knowledge frameworks that configure the global political economy, namely those of actually existing neoliberal capitalism’ (2016a, 1). This, they continue, has led to the ‘restructuring or privatisation of previously public institutions and public goods, including provisions for healthcare’ (2). Prominent examples of these public-private partnerships include the GAVI Alliance, which aims to improve health and development by increasing access to vaccines in poor and developing countries, as well as the Global Fund. Whereas for Gill and Benatar this has been problematic, in privileging profit over need in what they term the ‘market civilisation model of economic development’ (Gill and Benatar 2016a, 1), Williams and Rushton (2011) produce a more nuanced account, which although critical of certain aspects, sees benefits not least in the increased capital available for health needs. The fourth theme is the growth in the number and prominence of global health ­networks. Unlike the previous themes, this has received comparatively little attention,

272   Colin McInnes but as Shiffman and colleagues (2016) argue, transnational webs of individuals and organisations now exist for most major health issues and arguably have been a major factor in the global decline in morbidity and mortality since 1990. Moreover, they assert that ‘the proliferation of global health networks represents one of the most dramatic shifts in global health governance over the past decades’ (Shiffman et al. 2016, i4). Key to this has been the manner in which the dominant pattern of bilateral relationships between an international organisation, such as WHO, and member states has been replaced by looser, non-hierarchical relationships amongst heterogeneous bodies: ‘Networks are forms of social organisation distinct from formal hierarchies—such as states, international organisations and international NGOs. . . . In their voluntary membership, relatively diffuse systems of authority, and the rarity of a formal contract that binds them together’ (Shiffman et al. 2016, 3). These networks are usually issue specific and frequently demonstrate a normative commitment to alleviating a particular health burden. Some have been formalised (e.g., ‘Roll Back Malaria’), whilst others remain loose coalitions of those sharing an interest and with some capacity, whether in terms of action, advocacy, or knowledge. Finally, Jennifer Chan (2015) identifies a pattern of global interconnectedness in terms of advocacy for HIV and AIDS that may be repeated—though not always to the same extent—with other health issues. For Chan, the local (i.e., substate) and the global are intimately interconnected, such that activists working within states can use international agendas to promote their interests, whilst global initiatives can have local effects. Whereas the networks identified by Shiffman and colleagues are outside formal hierarchies, these patterns of interconnectedness can link markets, formal hierarchies, and informal networks in a complex tapestry of material and ideational factors that have transformed the landscape of GHG.

The Politics of Global Health Governance These developments in both the narrative of health—that ‘health is global’—and the transformed architecture of GHG have contributed to the increased profile of global health issues on international agendas—including those of the G7 (and previously G8), the G20, and UN—as well as those of individual states, most notably the massive US commitment to AIDS relief with PEPFAR. This has occurred for a number of reasons, including the increase in shared risk as a result of globalisation; the threat to national and human security; the macroeconomic consequences of health crises in a globalised economy; the new humanitarian agenda exemplified by the UN’s ‘Responsibility to Protect’ agenda (UN n.d.; Thakur and Weiss 2009); and the actions of powerful individuals promoting global health issues, from politicians such as WHO DirectorGeneral Gro Harlem Brundtland and former US President Barack Obama to celebrities

Global Health Governance   273 such as Bono and philanthropists such as Bill and Melinda Gates. But what do these developments mean for the politics of GHG? This concluding section identifies five key consequences of these two transformations for the politics of GHG. The first concerns the diffusion of power and authority across global health. This can be seen in a number of ways, but for heuristic purposes it can perhaps best be considered across two axes: a horizontal axis consisting of those international agencies working in health, and a vertical axis running from local organisations through national authorities (states) to global institutions. On the first, horizontal axis, WHO’s dominant position as the lead international agency promoting health worldwide has been diluted by the emergence of multiple other actors. The harbinger for this was when, faced with its poor record in limiting the spread of HIV and AIDS, WHO was forced to work with other UN agencies through a new umbrella organisation, UNAIDS. Not least, the emergence of multiple actors has affected WHO’s normative power as the leading voice for health promotion globally. During the West African Ebola crisis, for example, it was MSF’s Joanne Liu who focused world attention on the need for action and provided a normative context, not Director-General Margaret Chan (see, e.g., Frieden 2015). On the second, vertical axis, GHG is no longer so clearly dominated by states (with WHO as an intergovernmental organisation funded largely by states, and whose key decision-making bodies, the Executive Board and World Health Assembly, are dominated by states). Rather, it now consists of multiple different forms of national, international, and transnational actors, some formal and others less so. However, it would be wrong to infer from these two axes that WHO and states are no longer powerful actors in global health; indeed, they are amongst the most, if not the most, important voices. Nor is it to suggest that these features did not exist before the emergence of ‘­global health’. Rather, it is to say that their position is not as dominant as might have previously been the case, and instead we see a greater diffusion in power and authority. This assumes a ‘zero-sum game’, in which the emergence of new forces undermines the power and authority of existing actors. But what we also see occurring are elements of a ‘positive sum game’, in which these new actors have added to the power and authority of the sector in arguing for greater attention and resources. The clearest evidence for this is the increased funding for global health in the first part of this millennium, even after the financial crash at the end of the first decade. So although the power of established actors may have declined in relative terms within the field of global health, that of the field as a whole has increased in absolute terms. Related to this diffusion of power and authority are issues arising from the multilevel structure of global governance. GHG sits within a broader framework of global gov­ern­ ance, which includes not only bodies whose mandates cover multiple sectors (most notably the UN), but also other sector-specific bodies such as the World Trade Organization (WTO), the World Organisation for Animal Health (OIE), and the Food and Agriculture Organization (FAO). Moreover, sector-specific GHG provides a generic framework within which issue-specific governance frameworks operate. Issues such as HIV and AIDS, maternal health, and antimicrobial resistance (AMR) therefore all have identifiable governance regimes specific to their own area of health. Ideally, the relationship

274   Colin McInnes amongst these would be a hierarchical power relationship, whereby GHG is informed by wider trends and policies in global governance and in turn informs issue-specific governance. Through this nested relationship, policy coherence and consistency would be facilitated. An example of this might be recent policy initiatives on AMR. Within an overall governance framework, the highlight of which was a 2016 UN General Assembly High Level Meeting (WHO 2016), the three key governance actors in world health, food and agriculture, and animal health (WHO, FAO, and OIE, respectively) produced a tripartite collaboration to address this issue (WHO n.d.-b). The picture that emerges more generally from studies on how multilevel health governance operates, however, is less satisfactory (e.g., McInnes et al. 2014). Indeed, rather than a nested hierarchical relationship, multilevel governance resembles more a ‘bumper car’ track, on which different governance regimes as often collide with each other as work coherently together. An example of regimes bumping into each other on health-related issues is that of migrants: security regimes may frame the issue in terms of the benefits of limiting or even halting the flow of migrants into a country and recommend policies that detect and deport illegal immigrants; public health regimes may recommend less stringent measures to ensure access to migrants who may be vectors for the spread of disease and, if undetected because of fear of deportation, may pose a health risk to the wider community; and regimes focusing on rights may argue that host countries have responsibilities to people in need. Because power is diffused, different governance regimes ‘bump into’ each other as they pursue their own sectoral interests, whether it is one health issue colliding with another or health bumping into other sectors. The second consequence concerns funding, or the ‘power of the purse’. Even critics of WHO recognise the constraints placed on this key governance body in global health, not only by its lack of funding (WHO’s annual budget is comparable to that of a large city hospital in a high-income country), but also by the manner in which three-quarters of this budget is earmarked for purposes specified by donors and therefore not to be used at the discretion of the Organisation (Stocking 2015). However, the picture is more complex than a combination of underfunding and hypothecation limiting the power of WHO as an actor. The decade beginning in 2000 saw unprecedented levels of funding for global health initiatives—from multilateral public-private partnerships such as the GAVI Alliance and the Global Fund, to national programmes such as PEPFAR, to charitable donations, most notably Warren Buffet’s estimated US$30 billion donation to the Gates Foundation. Even following the 2008 financial crash, funding for global health remained relatively high (Murray and Dieleman n.d.). This is not to suggest that funding has been sufficient to meet global health needs because of this increase, but rather that a ‘market’ of funding has emerged. The power of the purse to set agendas has accordingly become more complex because of the multiple funding mechanisms and donors involved. This includes not simply the identification of which diseases need funding, but how to address issues (e.g., the tension between ‘vertical’ funding for specific diseases versus more generic health system strengthening) and funding modalities, which create power relationships between donors and recipients of aid (although recent work has suggested that power is not monopolised by donors, and civil society groups in receipt of aid may also exercise power over donors; see, e.g., Anderson and Patterson 2017).

Global Health Governance   275 A third consequence is that raised expectations for GHG have created challenges for the nature of political authority. In particular, the form of authority vested in ­gov­ern­ance bodies (especially WHO) may no longer be sufficient to meet the transformed expectations provided by the narrative of global health. But to grant these bodies different forms of authority may lead to a change in power relations between them and states. Avant, Finnemore, and Sell (2008) identify four different types of authority: • delegated authority, in which states have ‘loaned’ to a governing actor the ability to act in certain areas; • expert (or expertise-based) authority, based on the actor’s technical expertise; • principled (or principle-based) authority, based on acceptance of and adherence to a set of values; and • capacity-based authority, based on the actor’s competence and ability to undertake effective action. These different forms of authority are not mutually exclusive, but they do establish the parameters of a governor’s actions—both what it can (or cannot) do and also the expectations of what it should do given the nature of the authority accorded it. The utility of this framework is that it offers a means of understanding how the expectations of GHG are not being met. In particular, international and subsequently global health gov­ern­ance has traditionally been based on the first three forms of authority. Thus GOARN, for example, has expert authority to undertake disease surveillance; WHO has delegated and expert authority to provide guidelines on a range of health issues; UNAIDS, the body coordinating the work of UN agencies working on HIV and AIDS, has expert authority in providing technical details on issues such as the spread of the disease and levels of mortality; and MSF has principled authority based on its commitment to the health interests of individuals and communities. Regardless of the degree of authority, which may vary over time and from actor to actor, what is conspicuously absent is capacity-based authority: the ability to act. This has created a gap between expectations and capabilities, one ruthlessly exposed by WHO’s underperformance during the 2014– 2016 West African Ebola outbreak. But it has also created political tension over whether or not international organisations should be given the autonomy and capacity to act when confronted by a perceived health crisis. A final consequence concerns the normative basis for action arising from differences over what GHG is for. The multiple agencies and sectors involved have created a system in which there is no single, unifying idea, but rather competing visions (or ‘frames’). Frames operating within GHG include biomedicine, development, economics, rights, and security (Labonte and Gagnon 2010; McInnes et al. 2014). Each of these creates a different normative basis for GHG. The biomedical frame, for example, sees GHG as promoting human well-being, economics as contributing to macroeconomic growth, rights as protecting human dignity, and security as minimising risks and threats. The problem for GHG is not simply that this inconsistency weakens the case for action and undermines normative power, but also that these frames may be in competition with

276   Colin McInnes each other. Thus, in tobacco control the biomedical framing of the issue (privileging human well-being) contrasted with an economics frame (higher tax revenues) and the rights frame (the individual’s freedom to choose to smoke). This paralysed progress on tobacco control until both the rights and economics frames were successfully challenged on their own grounds (the right of non-smokers not to be affected by passive smoking, and evidence that suggested the economic gains through tax revenues were offset by health costs). On the other hand, the ability to co-opt multiple frames on a single health issue may create a broader constituency and a stronger basis for action. Thus HIV and AIDS was successfully presented as not only a biomedical challenge, but also a security, economic, and rights issue, creating a broad constituency for action in the first decade of the millennium and unparalleled levels of funding (McInnes and Lee 2012b; McInnes et al. 2014, esp. 59–77).

Conclusion In conclusion, GHG is evolving as a result of two transformations. The first concerns a discursive shift that implies a privileging of global concerns over national interests and the second the increasingly complex architecture of global health. These have created a new political landscape, in which the significance of global health may have increased on political agendas, but power and authority within the sector have been diffused; the creation of a ‘market’ for funding has affected how the ‘power of the purse’ operates; an increased expectation of the ability of global institutions to act to prevent or mitigate crises has created problems for the nature of authority; and competing norms have created competing agendas over what health is for.

Acknowledgements This chapter is based on research funded by the European Research Council under the European Community’s Seventh Framework Programme—Ideas Grant 230489 GHG. The author is grateful for the collaboration of partners on this grant in the developing of his ideas on GHG, particularly Adam Kamradt-Scott, Kelley Lee, Anne Roemer-Mahler, Simon Rushton, and Owain D. Williams. All views expressed are mine. I would also like to thank Kelley Lee for her comments on an early draft.

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Global Health Governance   279 Miles, Tom. 2015. ‘WHO Leadership Admits Failings over Ebola, Promises Reform.’ Reuters, April 19. http://www.reuters.com/article/2015/04/19/us-health-ebola-who-idUSKBN0NA12J 20150419. Moore, John. 2014. ‘Ebola: What Lessons for the International Health Regulations?’ The Lancet 384 (9951): 1321. doi:/10.1016/S0140-6736(14)61697-4. MSF (Medecins sans Frontieres). 2014. ‘Ebola in West Africa: Epidemic Requires Massive Deployment of Resources.’ http://www.msf.org/article/ebola-west-africa-epidemic-requiresmassive-deployment-resources. Murray, Christopher J. J., and Joseph Dieleman. n.d. ‘Global Health Funding Reaches New High as Funding Priorities Shift.’ Institute for Health Metrics and Evaluation. http://www .healthdata.org/news-release/global-health-funding-reaches-new-high-funding-priorities -shift. Nebehay, Stephanie. 2014. ‘Lack of Leadership Hurts Ebola Fight in West Africa.’ Reuters,  August 21. http://uk.reuters.com/article/2014/08/21/uk-health-ebola-msf -idUKKBN0GL25320140821. New York Times. 2015. ‘Reform after the Ebola Debacle.’ February 10. http://www.nytimes .com/2015/02/10/opinion/reform-after-the-ebola-debacle.html?_r=0. Shiffman, Jeremy, Kathryn Quissell, Hans Peter Schmitz, David L. Pelletier, Stephanie L. Smith, David Berlan, et al. 2016. ‘A Framework on the Emergence and Effectiveness of Global Health Networks.’ Health Policy and Planning 31 (supp. 1): i3–i16. doi:10.1093/heapol/czu046. Smith, Frank. 2010. ‘The False Promise of Global Governance during Transnational Outbreaks?’ Paper presented at International Studies Association Annual Convention, New Orleans. Spicer, N., and A. Walsh. 2011. ‘10 Best Resources on . . . the Current Effects of Global Health Initiatives on Country Health Systems.’ Health Policy and Planning (May 5). http://heapol .oxfordjournals.org/content/early/2011/05/05/heapol.czr034.full.pdf+html. Stocking, Dame Barbara. 2015. ‘Report of the Ebola Interim Assessment Panel.’ www.who.int /csr/resources/publications/ebola/report-by-panel.pdf. Thakur, Ramesh, and Thomas G. Weiss. 2009. ‘R2P: From Idea to Norm—to Action?’ Global Responsibility to Protect 1 (1): 22–53. doi:10.1163/187598409X405460. United Nations (UN). n.d. ‘Responsibility to Protect.’ http://www.un.org/en/genocideprevention /about-responsibility-to-protect.html. Williams, Owain David, and Simon Rushton. 2011. ‘Private Actors in Global Health Governance.’ In Partnerships and Foundations in Global Health Governance, edited by Simon Rushton and Owain Williams, 1–25. Basingstoke, UK: Palgrave. World Health Organization (WHO). n.d.-a. ‘Strengthening Health Security by Implementing the International Health Regulations (2005): Global Outbreak and Response Network (GOARN).’ http://www.who.int/ihr/alert_and_response/outbreak-network/en/. World Health Organization (WHO). n.d.-b. ‘FAO/OIE/WHO Tripartite Collaboration on AMR.’ http://www.who.int/foodsafety/areas_work/antimicrobial-resistance/tripartite/en/. World Health Organization (WHO). 2016. ‘United Nations High Level Meeting on AntiMicrobial Resistance.’ Youde, Jeremy. 2012. Global Health Governance. Cambridge, UK: Polity.

chapter 15

The State a n d Gl oba l H e a lth Ted Schrecker

Global health policy researchers investigate the activities of states (e.g., as providers of health services domestically and development assistance internationally) and are often funded by them through granting agencies. Global health practitioners routinely interact with state agencies, not only those that provide health services but also such actors as the bilateral agencies that disburse development assistance; indeed, the practitioners often work for them, either directly as employees or indirectly through grant-funded projects. Curiously, the social science literature on global health includes little theorizing, or even critical reflection, on the nature and role of the state. This is so despite the frequency of references, in discussions of global governance and health, to the supposedly ‘post-Westphalian’ character of the global health policy environment (see, e.g., Fidler 2004, 2007; Hein, Bartsch, and Kohlmorgen 2007; Hein and Kickbusch 2012). The central theme of this chapter is that reports of the death of the (nation) state have been exaggerated, and that claims about its declining relevance to global health policy and politics must be questioned. Thoughtful social scientists approach generalizations about the state with caution, but a few such generalizations nevertheless serve as starting points for discussion. While it is convenient to think of states as unitary actors, and they do function that way in contexts such as the United Nations General Assembly, the World Health Assembly (the annual meeting of World Health Organization [WHO] member states), and the gov­ern­ ance structures of the World Bank and the International Monetary Fund (IMF), in fact the internal organization even of so-called underdeveloped nation states is highly complex and often conflict ridden. For example, it has been claimed that ‘most health ministers lack domestic political muscle. They might talk tough among themselves [in the international arena] . . . but back home they have to get in line behind colleagues in finance, defense, trade and even education’ (‘What Can the UN General Assembly Do’ 2013). Whether or not this is true—and this is the kind of generalization that must be approached with caution—the observation underscores the internal complexity of

282   Ted Schrecker states and their decision-making processes. Federalism and devolution introduce ­additional layers of complexity and potential conflict, not least because ‘[i]n practice federalism is not a free choice, but a function of the political power of territorial minorities, at least when war and other means of open coercion are excluded as possible options’ (Hueglin 1987, 34). More fundamentally, the conventional Weberian definition of the state refers to the organization with a monopoly on the effective or legitimate (contemporary formulations vary) use of force or violence within a given territory. Whatever one’s view of North and colleagues’ rather ambitious claim to have developed ‘a conceptual framework for interpreting recorded human history’, their work (North et al. 2009; North et al. 2013) reminds us that such monopolies are a relatively recent historical phenomenon (cf. Tilly 1985), and that in much of the world states are characterized by ongoing contests among elites over access to the means of violence, with civil conflict as the not-infrequent outcome. This point should be central to understandings of global health politics, given the horrific toll of injury, illness, and death associated with such conflicts (Levy and Sidel 2007, 2016). Research on health policy in states outside the ‘developed’ world often appears to presume that processes of policy formation and implementation and political choice in such jurisdictions operate more or less the same way they do in the limited number of high-income countries (HICs) that North and colleagues characterize as open-access orders: a shorter list of countries than those that possess a minimal set of formally democratic institutions. In a spirit of methodological self-consciousness, such presumptions must be guarded against. Rather than taking for granted the state’s functions and functionaries as they relate to healthcare and other prerequisites for healthy living (the social determinants of health), it is more productive to ask: Why do states care about health? Whose health? And under what conditions are they more or less likely to do so? The next two sections expand on what is, and is not, known about these questions.

Health within Borders Almost all states provide and finance some healthcare, although in many low-income jurisdictions budgets are comparatively minuscule. It is a bitter irony that the lower the per capita income in a country, the larger the proportion of healthcare that is financed out-of-pocket, leading to a pernicious poverty trap. However, there is no direct correlation among per capita income, public spending on health, and health outcomes. For example, Drèze and Sen point out that India ‘is falling behind every other South Asian country (with the exception of Pakistan) in terms of many social indicators, even as it is doing spectacularly better than these countries’ in income growth (2013, 50–54). Notably, on indicators such as child mortality, access to improved sanitation, and immunization, India’s performance lags behind that of substantially poorer Bangladesh, such that Drèze and Sen characterize the country as facing a healthcare crisis (143–181). Shortly after their book appeared, a newly elected national government announced a

THE State and Global Health   283 16 percent cut in its health budget (Mudur 2015). Similarly, in 2010 African Union finance ministers sought (unsuccessfully) to get their governments to abandon an earlier commitment to increase spending on health to 15 percent of general government spending (Njora 2010)—a target that few countries in the region had or have met (African Union 2013). At least until recently, and despite provocative comparisons like Szreter’s (1999) between the situation in fast-growing, nineteenth-century England and contemporary emerging economies like China, the research literature has been relatively uninformative about why health and policies that improve healthcare access and quality (and prerequisites for health like access to safe drinking water and improved sanitation) feature more prominently on some state agendas than on others. Such questions are newly relevant as universal health coverage (UHC) has become firmly established on the development policy agenda (e.g., as the topic of a 2012 UN General Assembly resolution [United Nations 2012], a target under the United Nations’ 2015 sustainable development goals [SDGs], and an agenda item for the 2016 G7 Summit), although some uncertainty exists about the meaning of UHC (Sengupta 2013; Stuckler et al. 2010). A Chatham House analysis of the financing challenge used an average estimate of US$86 as the price in 2012 of a set of ‘priority services’ for the entire population in low-income countries (LICs)— not, it must be emphasized, anything like the healthcare most residents of HICs take for granted—which, compared with domestic public spending on healthcare in sixty-one countries, implied an annual ‘financing gap’ of US$196 billion (Centre on Global Health Security 2014). Had governments in all countries spent even 5 percent of GDP on healthcare, this gap would have fallen to US$65 billion, demonstrating not only the need for additional development assistance for health but also, and more important for this discussion, the need to understand that moving toward UHC is inescapably political (and politicized). It entails not only raising additional revenues and shifting spending priorities but also redistributing resources from the relatively wealthy and healthy.1 When are states more or less likely to make such commitments? The question is of more than academic importance, given, for example, the finding of Lu et al. (2010) that increased development assistance for health to governments is associated with reduced health spending from domestic sources. A rapidly expanding descriptive and technical literature on progress toward UHC offers relatively few insights. In the body of work that more explicitly considers this ­political dimension, Pisani et al. (2017) argue that the economic crisis of 1997, followed by democratization the following year, created a climate in Indonesia in which initially far-reaching reforms were gutted by resistance from established interests, but ‘different groups obtained access to health care as their socio-political importance grew’ (274), aided by political decentralization in 2005, which encouraged experimentation at the local level. A review of experience in eleven countries found that UHC often advances in conjunction with major social or political change; is facilitated by the existence of social movements and strong executive leadership; and usually proceeds incrementally, providing ‘insurance coverage to civil servants and formal sector workers first because these groups are politically influential’ (Reich et al. 2015, 813).

284   Ted Schrecker Especially interesting is the work of Kelsall, Hart, and Laws (2016) on the conditions under which ‘political settlements’ are more or less likely to advance progress toward UHC. Although multiple definitions of political settlements exist, it suffices here to quote two: ‘the forging of a common understanding, usually between political elites, that their best interests or beliefs are served through acquiescence to a framework for administering political power’ (UK Department for International Development, quoted in Di John and Putzel 2009, 4) and, in a formulation that recalls the analysis of North and colleagues, ‘the set of institutional relationships through which a country restrains violence’ (B. Levy, quoted in Kelsall et al. 2016, 7–8). This approach recognizes the importance of renewed attention to state and nonstate elites and their interactions— an approach that until recently had fallen out of favor in the study of national and subnational politics. Kelsall and colleagues attempt to apply a fourfold typology of political settlements to six low- and lower-middle-income countries, with results that they concede are inconclusive, partly because of the unevenness in progress within countries. Such typologies are probably less useful than the underlying insight that the distribution of political resources within societies is fundamental to understanding prospects for UHC; is influenced powerfully by historical considerations (and in many circumstances also by external actors); and may involve situations in which large portions of the population have little or no influence over the terms of the political settlement, except when extraordinary events create volatile situations and the potential for large-scale social change. Put more simply, any approach that treats states and ­political systems as ‘black boxes’ will contribute little to our understanding of such issues as progress toward UHC. Healthcare policy and financing are only part of the picture. Given what is now known about social determinants of health (Commission on Social Determinants of Health 2008; Kelly and Doohan 2012), it is axiomatic that health is influenced by much more than the availability and quality of healthcare. Correspondingly, state policies in many areas are implicated in the level and distribution of health outcomes. Of notable importance are policies that affect levels of poverty and economic inequality (and thereby such variables as nutrition), access to safe drinking water and sanitation, and exposure to hazardous living and working conditions. Reflecting the complexities referred to in the chapter’s introduction, it cannot be assumed that health will have the same priority across policy fields. As an example of the uneven progress within countries noted by Kelsall and colleagues, Chowdhury et al. (2013) note the ‘Bangladesh paradox’, in which more favorable health outcomes than would be expected given the country’s poverty, and a strongly equity-oriented approach to health system design, coexist with pervasive poverty and high prevalence (nearly 50 percent) of child malnutrition. The garment industry that is Bangladesh’s major export success story is becoming notorious for industrial accidents reminiscent of the Triangle Shirtwaist fire a century ago in New York City (Brooks 2007, 85; Yardley 2012), arguably reflecting a ­political context in which 10 percent of national legislators are garment factory owners (Yardley 2013), and literally thousands of former public servants and army personnel

THE State and Global Health   285 were able to use their proceeds from their roles to ‘buy in’ to the early stages of that industry (Khan 2013, 52–53). Poverty, in particular extreme poverty (however defined), is one of the most basic social determinants of (ill) health. Sumner (2010) argues that opportunities for reducing extreme poverty have changed now that roughly 70 percent of the world’s poorest people no longer live in the world’s poorest countries. He and a colleague make the provocative claim, based on admittedly imprecise estimates, that two-thirds of extreme poverty as defined by the World Bank (at this writing, US$1.90/day at 2011 purchasing power parities) could be completely eliminated using domestic revenue sources if countries eliminated regressive fossil fuel subsidies and reduced their military spending as a proportion of GDP to the lowest in their region; levying modest marginal taxes on (relatively) higher incomes would make possible the complete elimination of extreme poverty, the very first target under the SDGs (Hoy and Sumner 2016). This is reminiscent of an earlier World Bank argument that ‘[a]s average incomes rise, the number of poor will shrink and the tax base will grow, making effective assistance easier to provide and social safety nets a viable remedy for increasing inequality’ (World Bank 2007, 69). The appropriate definition of extreme poverty is a topic of ongoing controversy (Hickel 2016), but the structure of this argument as it relates to fiscal capacity is homologous to the Chatham House argument about funding UHC—and likewise directs our attention to the relationship between states and their subjects. Hoy and Sumner concede with masterful understatement that ‘the political economy of redistribution would of course not be easily navigated,’ but state their argument in terms of ‘a choice or contract that government or elites make with the rest of the population’ (2016, 1; emphasis added). This perspective arguably embodies a fundamental misunderstanding of the distribution of power and resources and the nature of relations between rulers and ruled in much of the world. This is not to suggest that redistributive policies in such contexts are not a priori implausible, as (for example) the proliferation of conditional cash transfer (CCT) programs, especially in Latin America, makes clear (Bastagli 2009; Molyneux 2007). It is to suggest that, as in Brazil—where the Bolsa Família CCT program has reduced poverty and a major roll-out of primary care has expanded access to health services (Macinko et al. 2010)—a political trade-off may be evident in transfers to elites that are much larger in absolute budgetary terms (Hochstetler 2014). A further dimension of this trade-off involves the use of state power and resources, including public financing, for the ­construction of luxury housing, in association with such elite projects as the Pan American Games and the Olympics (Gaffney 2015; Grix and Lee 2013; Sánchez and Broudehoux 2013). This example, drawn from a federal state with formally democratic institutions during a period of left-of-center national government, illustrates the complexity of the political science of social determinants of health and health inequalities. Further, such public subsidies for private elite accumulation also characterize urban policy in states that meet the test of an open-access order, suggesting that at least with respect to the redistributive policies that are central to reducing health inequalities, the boundary line may be unclear and permeable.

286   Ted Schrecker

Health Beyond Borders: Global Health Politics and Policy (In)coherence Similar complexities characterize the relatively recent emergence of global health as an item on the foreign policy agenda—and here the focus shifts to the HICs. Although global health’s importance in such fora as the G7/G8 waxes and wanes, it has intermittently been prominent on summit agendas. The G7/G8 were important in establishing the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria (for details on the Global Fund see Bartsch 2007; Kapilashrami and Hanefeld 2014), and summits (with Japanese leadership) have been important milestones in placing UHC on the development policy agenda (Reich and Takemi 2009; Takemi and Reich 2009). In parallel with the question asked previously about states and the health of their citizens, we should ask: Why do states care about the health of those outside their borders? And what affects their priorities? For it is clear that they do care, at least some of the time. In addition to the developments just cited, one indication is the value of development assistance for health, which more than quadrupled in real terms between 1990 and around 2010 (Dieleman et al. 2016), and although the value stabilized after the financial crisis, the sums in question did not decline substantially, as many had feared. What motivates such concerns, what accounts for priorities, and what explains the differences among states? It is axiomatic that security (of nation states in geopolitical terms, and of people within their borders, in particular with regard to communicable diseases) is the oldest and often dominant motivation and tends to crowd out other motivations. As an extreme example, in December 2014 President Barack Obama called on Congress to appropriate US$6.2 billion in emergency funding to fight the Ebola virus, although three months later there were only four confirmed cases in the United States. Looking further back, at the turn of the century the HIV/AIDS epidemic was considered ‘a threat to both human and national security,’ in the words of a background document for the first-ever UN General Assembly Special Session on a health topic (United Nations 2001). Despite the epidemic’s devastating effects on life expectancy in several sub-Saharan countries, the more apocalyptic predictions of effects on social and political stability failed to materialize (Fourie 2007). Security concerns on their own no longer provide a sufficient explanation, and Ingram has gone to some lengths to distinguish the response to AIDS as a ‘biosecurity’ issue (in Foucauldian terms) from the institutional forms in which concerns about security associated with ‘outbreak-type events’ (2010, 299) have been manifested. However, HIV/AIDS continues to draw a large portion of some development assistance budgets: almost 30 percent of all development assistance for health in 2015 (Dieleman et al. 2016). The United States, where the epidemic was intensely politicized early on, accounts for a large proportion of this amount; more than half of all US development assistance for health in recent years has gone to HIV/AIDS (Dieleman, Graves, and Johnson, et al. 2015). No evidence suggests that this consistent commitment arose from security

THE State and Global Health   287 concerns; rather, it appears to be the result of an improbable bipartisan coalition in support of the President’s Emergency Plan for AIDS Relief (PEPFAR) (Messac and Prabhu 2013), in the face of think-tank warnings that the program was ‘hard to justify on investment grounds’ and that the United States should ‘moderate the expansion of treatment entitlements’ (Over 2008). The next two largest sources of development assistance for health, the United Kingdom (where no comparable social movement around AIDS developed) and private foundations, devote far smaller proportions of their budgets to HIV/AIDS (Dieleman et al. 2015). This is one clear demonstration of a connection between domestic priorities and international commitments. Another, especially serious given the growing burden of non-communicable diseases (NCDs), involves the limited amount of development assistance for health going to their prevention and control, or even to maternal, newborn, and child health, although the contribution of NCDs to the burden of illness in low- and middle-income countries (LMICs) is comparable if not larger (Dieleman et al. 2015; Nugent & Feigl 2010). Hard evidence is lacking, but legal scholar David Fidler rather sardonically suggests one explanation: ‘Although political and economic connections and interactions between the United States and India are increasing, neither national health nor economic prosperity in the United States depends on whether India controls obesity related diseases, and vice versa’ (2011, 36). Development assistance is hardly ever motivated solely by altruistic considerations, but the case for considering altruism as significant is stronger than in the past, given the (hard-fought) decline of the practice of tying aid to domestic purchases (OECD Development Assistance Committee 2015), although both economic and geostrategic considerations still act on the choice of aid recipients (see, e.g., Dreher, Nunnenkamp, and Schmaljohann 2015). Indeed, historically these have arguably been the primary motivations for US development assistance, and at this writing a return to that pattern is certainly possible in the context of President Donald Trump’s ‘America First’ policies and the inward-looking turn in the UK exit from the European Union. Research on how priorities for development assistance are determined provides little guidance about influences on the relative priority attached to health, with the conspicuous exception of PEPFAR. WHO (2015) is now promoting Health in All Policies as a rubric for integrating concerns about health, in particular health inequalities, into all areas of public policy. If few states are committed to this goal domestically, it remains even more remote and elusive in foreign policy. For example, states routinely promote the commercial interests of firms located in their territory at the expense of health—a tension that is often referred to in discussions of trade and health in terms of a lack of policy coherence (e.g., Blouin and Drager 2015). The Canadian government defended asbestos exports despite intense global criticism and unanimity in the reputable scientific community about the substance’s dangers (Attaran, Boyd, and Stanbrook 2008; Kirby 2010), long after their economic value had dwindled to insignificance, because of the industry’s symbolic significance in the politically volatile province of Québec. In a higher profile example, both the United States and the European Union claim to support expanded access to essential medicines, yet they pursue expanded intellectual property protection that threatens to thwart that

288   Ted Schrecker objective through ‘TRIPS-plus’ provisions in bilateral and regional trade agreements and seek to deter countries from using the flexibilities that are allowed under trade agreements using unilateral mechanisms like the US Section 301 Priority Watch Lists and the European Commission’s priority country list (Health Action International and Médecins sans Frontières 2015; United Nations Secretary-General’s High-Level Panel 2016; Zhou 2016). Unfortunately the literature on policy incoherence in trade and health is mainly descriptive and does not investigate the underlying political economy. This is an important omission because lack of policy coherence is not confined to trade policy; it extends, for example, to the destructive consequences of the economic restructuring demanded of LMICs by the World Bank and IMF, with the widely used phrase ‘the Washington Consensus’ (Williamson 1990) betraying its origins. Against this background, in 2015 the UN General Assembly adopted a set of ambitious SDGs, the achievement of which will require by one estimate annual public and private investment of US$2.5 trillion (UNCTAD 2014), compared to current development assistance of approximately $135 billion. Expansion of health coverage is one of the targets associated with the SDGs; so, too, are a variety of health-related outcomes in the areas of poverty reduction, food security, and environmental exposures. If adoption of these goals is understood as more than simple hypocrisy on the part of states that have no intention of mobilizing the necessary resources, which cannot be ruled out, then a variety of tensions between economic or commercial and health policy objectives will arise, of which two of the most important are addressed here. First, the fiscal burden of foreign debt for many LMICs was succinctly described by an advisory body to the UN Secretary-General in 2005: ‘[D]ozens of heavily indebted poor and middle-income countries are forced by creditor governments to spend large parts of their limited tax receipts on debt service, undermining their ability to finance investments in human capital and infrastructure. In a pointless and debilitating churning of resources, the creditors provide development assistance with one hand and then withdraw it in debt servicing with the other’ (UN Millennium Project 2005, 35). Subsequent debt cancelation initiatives eased some elements of the burden, but it has actually worsened in other respects: ‘Annual debt service on external debt has risen to US$575 billion, about four times the amount that is reported as official development assistance (ODA). The first developing country debt crisis is therefore the crisis of opportunity costs. Each dollar that is transferred to creditors abroad is a dollar that goes missing to finance the implementation of the SDGs at home’ (Ellmers 2016, 7). Second, tax avoidance by transnational corporations (TNCs) and ultra-wealthy individuals is increasingly recognized as potentially destructive of the fiscal capacity of most states and of special importance to LMICs that are committed to such objectives as progressing toward UHC, yet efforts at multilateral cooperation are likely to encounter serious domestic resistance from several quarters, in jurisdictions across the income spectrum. If it is too much to hope for a health-in-all-policies orientation in foreign policy, even a ‘first, do no harm’ position would be an improvement on current practice.

THE State and Global Health   289 The reasons for such policy incoherence arise in the first instance from unequal domestic distributions of political resources—described in the pre-globalization era in terms of the ‘privileged position of business’ in the politics of market economies (Lindblom 1977, 170–221).2 That privileged position, even under conditions of formal democracy, arises from the dependence of the economies in question on private investment and from the ability of private investors (or capitalists), within very broad limits, to withhold that investment until conditions are more favorable.3 This privil­ eged position is readily observable in the course of trade negotiations and disputes. Major tobacco firms and pharmaceutical companies often met privately and directly with European Commission officials during negotiations on the Transatlantic Trade and Investment Partnership (TTIP) (Gallagher 2015). In the United States, corporate representatives dominated the advisory committees that had access to successive negotiating drafts of the Trans-Pacific Partnership (TPP) (Ingraham and Schneider 2014; Palmberg 2012), which were not available to citizens and legislators. Some dis­ agreement is associated with whether disparities of this kind in access to the policy process provide explanations (as suggested, e.g., by Kaminski 2014) or demand them. In either case, globalization clearly magnifies the privileged position of business. Powerful pressures for policy convergence arise from competition for direct investment and contract production (see chapter by Schrecker on critical approaches to international political economy and global health in this volume), under conditions in which the lowering of trade and investment barriers has increased the ease with which capital can exercise its exit option, and from the fact that almost all governments must look over their shoulders to gauge the reaction of financial markets to their policies (Mosley 2003; Schäfer and Streeck 2013), although the degree of constraint involved varies considerably. At the same time, the degree to which constraints associated with globalization reduce or eliminate policy space can be exaggerated.

Reports of the Death of the State Have Been Exaggerated Reports of the death, or at least the declining relevance, of the nation state now emanate from several quarters. At least three lines of argument have special relevance for global health policy and politics. First, it has been claimed that pressures for global economic integration and domestic policy convergence are making national politics all but irrelevant. In 1995 Strange wrote ‘that the political choices open to governments these days have been so constricted by those forces of structural change often referred to as “globalization” that the differences that used to distinguish government policies from opposition policies are in process of disappearing’ (1995, 291; for a similar, contemporaneous view see Schmidt 1995). Second, as noted at the start of the chapter, several observers of global health policy assert that its environment is now post-Westphalian, characterized

290   Ted Schrecker inter alia by a proliferation of nonstate actors—civil society organizations, private foundations and transnational corporations among them—that routinely operate both within and across national borders. Third, in a similar vein Robinson (2004, 85–144) in particular argues that, in parallel with globalization and the emergence of a transnational capitalist class (Carroll 2010; Robinson and Harris 2000; Sklair 2005; van Fossen 2012), a nascent transnational state can be observed. It comprises a variety of economic and political organizations and governance frameworks, including the development banks, the WTO, forums like the G7, and the supranational administrative structures established under trade and investment agreements. This observation is intriguing and important even if one questions the notion of a transnational capitalist class.4 Each line of argument points to important features of global health politics and the role of the state, but each also runs the risk of overstating a case. To take first the claim about the transnational state, it is beyond serious dispute that agencies like the World Bank and IMF, in their role as sources of both finance and technocratic expertise, wield considerable influence over LMIC governments, and that their alliances with domestic elites and political executives can circumvent many routes of domestic political accountability (Stichelmans 2016; and see Babb 2002 for a case study on Mexico). At the same time, decision-making in those organizations is controlled by the governments of member countries, primarily by a few large, rich members (on the consequences for managing the Greek debt crisis, which has already had important health impacts, see Thomas 2016). Apart from the important ability of institutions like the World Bank and IMF to offer or withhold finance and to act as gatekeepers with respect to funds from other sources, what Robinson calls the transnational state relies for its ‘hard edge’ almost exclusively on the powers of nation states. Even the arbitration mechanisms that enforce investor-state dispute settlement provisions of trade and investment agreements rely on national court systems for enforcement, and the agreements themselves are between nation states; that is the basis for their grant of legal standing to private actors. Thus, whatever state-like characteristics the transnational state possesses, it is a different kind of organism from the state at the national or subnational level, just as the ‘bindingness’ of international law is normally quite distinct from that of domestic law in its mechanisms of operation. Claims about a post-Westphalian environment likewise capture important elements of contemporary global health politics. Transnational civil society networks have exerted substantial influence on issues such as intellectual property protection, the pricing of medicines, and—in the broader development policy context—debt relief (the Jubilee 2000 campaign). On global health policy and related areas of development their research is often of higher quality than that emanating from the academic world, and certainly more timely. Private philanthropies—the Bill and Melinda Gates Foundation, which spends more annually on health than the core budget of WHO, in particular— have emerged as important sources of finance for global health interventions and influences on the policy agenda (Birn 2005, 2014; McGoey 2014). Arguably the quintessential post-Westphalian institution in global health is the H8, an informal policy forum comprising WHO; three other UN system agencies; the Global Fund and GAVI

THE State and Global Health   291 (­formerly the Global Alliance on Vaccines and Immunization), which are themselves hybrid public-private entities; the World Bank; and the Gates Foundation. And a very large proportion of the global economy—four-fifths of world trade, by one estimate (UNCTAD 2013)—is organized by TNCs. Here again the case can be overstated. For the moment, many forms of international action only operate effectively through agreements among nation states; trade and investment agreements are a case in point. National governments continue to be the major funders of the Global Fund and GAVI and will be central to any advance toward UHC. Whatever one’s view of the prospects for transnational arrangements to control destructive practices like tax avoidance and the spread of antimicrobial resistance, which are important if not crucial to the future of global health, it is difficult to envision these taking any form other than agreements among nation states. Describing the global health policy environment as post-Westphalian is probably less useful than focusing on ‘power asymmetries’—a concept that was central to the work of the Lancet-University of Oslo Commission on Global Governance for Health (Ottersen et al. 2014)—between large and small nation states and between those actors empowered by access to the means of violence (whether through the state or in spite of it) or ownership of capital5 and those lacking such resources. Finally, there is the issue of pressures for policy convergence on a broadly neo-liberal model of economic and social policy. Although these pressures are crucial, more than twenty years later Strange’s warning strikes us as hyperbole. Such pressures have been substantial and may become more pressing in future, notably as the debt/GDP ratios in many HICs continue to rise (Schäfer and Streeck 2013). It is useful first of all to distinguish between the effects of pressures for policy convergence within national borders and the continued divergence of policies among countries that are, broadly speaking, similarly situated. Important explanatory variables are likely to be quite different. High-income countries vary threefold in the amount of poverty, on a standardized cross-national comparative measure, they are prepared to tolerate (Schrecker 2016); sub-Saharan countries’ public spending on health as a proportion of GDP varies by a factor of more than five, and the differences are not explicable with reference to national income levels (African Union 2013) although, as noted previously, more research on what explains the variations is urgently needed. Understanding global health politics requires investigating not only the nature of pressures for convergence but also, and critically, how domestic elites use the global context to advance their own agendas through alliances with actors such as TNCs and the IMF (Carroll 2010, 123–124), for example using IMF policy preferences as ‘political cover’ (Caraway, Rickard, and Anner 2012; see also Rogers 2009) or using trade agreements to lock in market-oriented policies against possible future alternatives. It is difficult to improve on Halperin’s formulation: ‘Globalization is a matter of deliberate organization and collective effort on the part of elites concerned to maintain a specific distribution of resources that subordinates labor and preserves elite privileges. The discourse of globalization emphasizes the necessity of governments to adapt to newness and difference, a necessity that forecloses choice. But government policies are designed, not to adapt to new circumstances, but to ­promote them’ (2013, 224).

292   Ted Schrecker

Conclusion The second and third sections of this chapter explore the questions of why states care about health, whose health they care about, and the conditions that affect these outcomes. The following section explores claims about the declining relevance of the state in the context of contemporary globalization, finding these to have considerable merit but also to be overstated. Nation states will continue to matter a great deal in any plausible scenario for the future of global health policy and politics. Where does that leave us? It is almost an academic ritual to conclude a chapter of this kind with the observation that more research is needed, yet in this case the observation is both appropriate and urgent. Far more needs to be known, and to be reported in the academic literature, on how states make policies that affect health and what role (if any) health plays in these processes. The focus in this chapter has been on nation states and national governments, since these are the primary state actors in global health policy. However, they are not the only state actors that matter, and a conception of global health policy that is sufficiently expansive to enable understandings of such issues as progress toward UHC must include subnational levels of government, especially (but not only) in federal systems. To provide an illustration, with diversity among India’s states that is comparable by some indicators to the differences among member countries of the European Union (‘Banyan’ 2017), many discussions of ‘India’ that do not account for actions at the state and federal levels are as likely to confuse as to enlighten. Additional work that generates fine-grained understandings of the distribution of political resources, the role of political institutions, and the orientations and allegiances of elites— to select just three topics—will be instructive and richly rewarding. This is perhaps an unsatisfying conclusion, but it fairly reflects the state of knowledge in the field.

Notes 1. Recognizing the critical importance of public finance to the public’s health, the analysis also emphasizes the importance of such matters as international cooperation to limit tax avoidance and the consequent limitations on governments’ fiscal space. 2. I have cited a leading liberal democratic theorist rather than any one of several Marxist formulations that are arguably more analytically rigorous (e.g., Offe 1984), in order to demonstrate the breadth of this understanding, even though it often remains in the background of policy analysis. 3. Thus, it was reported in 2016 that US-based TNCs held US$2.5 trillion in cash reserves outside the United States, associated with earnings booked abroad and internal transfers to foreign subsidiaries and affiliates, partly because of reluctance to repatriate the profits given relatively high US corporate tax rates (Cox 2016). 4.  In my view the emergence of such a class is now empirically observable beyond serious dispute, even as its boundaries remain contestable. 5. Which is only reliably established through a state-based system of property rights. The situation of early post-Soviet Russia shows what happens otherwise, and that legally enforceable property rights and access to effective means of violence are under some conditions substitutable one for the other.

THE State and Global Health   293

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chapter 16

Em ergi ng Pow ers a n d Gl oba l H e a lth G ov er na nce The Case of BRICS Countries Yanzhong Huang

Profound changes since the 1990s have shaped the landscape of global health ­gov­ern­ance (GHG). These changes have altered the scope and seriousness of the global health challenges faced and highlight the limits of existing processes and institutions in addressing these challenges and mitigating their effects. It is within this gap, between the collective action needs and the coping capacities of existing institutions, that the potential role of emerging powers as a growing force in GHG is underscored. Combined, the BRICS countries (Brazil, Russia, India, China, and South Africa) account for more than 25 per cent of global gross domestic product and 40 per cent of the world’s population. The vast rebalancing of wealth across the globe has nurtured a growing expectation that these ascendant powers can and should leverage their increasing influence to address global governance problems. Former WHO Director-General Margaret Chan (2011) noted, ‘BRICS represents a bloc of countries with . . . great potential to move global public health in the right direction . . . toward reducing the current vast gaps in health outcomes and introducing greater fairness in the way the benefits of medical and scientific progress are distributed’. A widely cited study published in 2012 echoed these expectations, arguing that a paradigm shift in global health is underway, because BRICS ‘represent[s] a potentially transformative source of new resources and innovations for global health and development’ (Tytel and Callahan  2012, 11). These countries themselves still confront tremendous domestic health challenges, and there are major differences among them in terms of political institutions, economic structures, and foreign policy. Yet as Ruger and Ng (2010, 20) observe, emerging countries are in an interesting

302   Yanzhong Huang position because ‘[t]heir still-transforming economies and health systems connect them directly to the concerns of the developing world, while their growing economic and political clout give them a place at the table with industrialized countries and a more powerful voice in global affairs’. This chapter discusses the profound implications arising from the growing and future role of emerging powers in GHG. What role have BRICS countries played in shaping GHG vis-à-vis domestic-health-related demands? To what extent has their status as emerging powers led them to play a distinctive role and promote a separate agenda from more established powers in GHG? How viable and sustainable is emerging powers’ engagement in GHG? In assessing the role of China and India in GHG, Huang (2013) adopts an analytical framework that focuses on health-related development assistance, the development of and compliance with global health rules, and the promulgation of ideas for GHG. This approach is built on a heuristic device first developed by the critical theorist Robert Cox (1981), who identified the combination of three ‘categories of forces’ to constitute the ‘anatomy of influence’ or ‘framework for action’: material benefits, institutions, and ideas. Harmer and Buse (2014), too, drew on Cox’s work in describing BRICS nations’ contribution to global health. Given the similarities of the subject matter, this chapter adapts a similar three-force analytical framework—institutional influence, material capabilities, and competing visions—to examine the influence of emerging powers in GHG. An examination of BRICS countries’ vision, institutions, influence, and material capabilities shows a distinctive and positive role they can play in GHG, especially in terms of providing development assistance for health (DAH), developing and participating in global-health-related institutions, and presenting an alternative vision of GHG. Their influence in engaging GHG nevertheless remains conditioned and constrained by their relatively small DAH size and a selective and state-centric approach to GHG, which undermines the robustness and attractiveness of their vision of it. Future research should pay more attention to exploring the incentives and capabilities of BRICS countries’ GHG involvement.

Institutional Influence Global governance encompasses ‘the totality of institutions, policies, norms, procedures and initiatives’ through which states and nonstate actors respond to transnational challenges (Committee for Development Policy  2014). Institutions that affect GHG therefore can be organizational or rule-based. Over the past couple of decades BRICS nations have become increasingly involved in the development of institutional instruments for GHG.

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The Venues for Engagement The BRICS countries can exercise their influence through their domestic agencies, the institutions that are forged among themselves, or broader international health organizations or rules. As far as domestic institutions are concerned, many governmental and nongovernmental actors may become involved in global health. Besides ministries of health and foreign affairs, other national-level, government development agencies can play a prominent role in conducting health diplomacy. They include Agencia Brasileria da Cooperação or ABC (Brazil), RUSAID (Russia), Development Partnership Administration (India), and Development Bank of Southern Africa (South Africa). For now, there is no single ministry or specialized development agency analogous to the USAID (US) or DFID (UK) in BRICS countries to oversee health-related development assistance and engage global health at a substantial level. The launch of a development aid agency was a very recent development in India, Russia, China, and South Africa. This might explain why nonstate actors or public-private partnerships play a more influential role in Brazil, India, and South Africa. Both the Public Health Foundation of India and the Rio-based Fundação Oswaldo Cruz (Fiocruz) are prominent actors in conducting internationalhealth-related cooperation. In South Africa the Treatment Action Campaign was important in fighting big pharmas in the early 2000s for access to antiretrovirals (ARVs) (Harmer  2014). By contrast, social institutions in China and Russia are largely controlled by the state and are far less influential in engaging global health. In the absence of strong national-level institutional frameworks for global health and development assistance, emerging powers have long relied on existing multilateral agencies (World Health Organization [WHO], World Bank, UN Development Programme [UNDP], and World Trade Organization) to conduct health diplomacy. However, their engagement has been driven by different reasons with different institutional focus: Russia turns to the World Bank and UNDP to manage the transfer of its overseas development assistance, while China relies on WHO as a critical venue in disease prevention and control. Unlike China, India has not shown strong interest in using WHO as a venue for agenda setting or rule making. Indeed, many in the country have regarded the World Bank more highly than WHO (Huang 2013). Since the 1990s plurilateral summit institutions (PSIs) have become an increasingly significant forum to address major global challenges. Unlike traditional, inclusive international organizations, summit-level clubs such as the G8 and G20 feature limited membership and increased flexibility in terms of issues to address. The smaller number of key stakeholders in a less formal, more authoritative setting not only allows for more substantive discussions about global challenges that member states have to confront, but also makes it easier for them to overcome collective action problems in reaching consensus and implementing decisions. Among BRICS countries, while

304   Yanzhong Huang only Russia is a member of the G8, all the leading emerging economies participate in the G20. Russia’s initial efforts to exercise global health leadership within the G8 was demonstrated at the 2006 St. Petersburg Summit, during which health was chosen as one of the top priorities. When participating in these institutions, BRICS nations so far seem reluctant to commit to a collective position beyond general endorsements of support. Instead, they prefer to have the flexibility to adopt individual positions on the issues in question (Harmer and Buse  2014). As Andrew Harmer (2014) noted: ‘there are few tangible examples of the BRICS countries working together on health’. Occasionally BRICS countries were united in their efforts to promote agendas of common interest (e.g., universal access to quality health technologies) (Gautier et al.  2014). Depending on the issue, they may also form ad hoc, temporary partnerships. For example, Brazil and India cooperated on intellectual property (IP) and universal access to medicines, while China, India, and Russia joined together on health security and surveillance issues (Gautier et al. 2014). Their level of involvement in WHO also varies. During WHO reform debates, for example, Brazil was the most active among the BRICS nations, followed by India, South Africa, China, and Russia (the least active) (Gautier et al. 2014). Over time, BRICS countries have recognized the need to offer a more unified, distinctive voice and perspective on global health, while enhancing cooperation among themselves. This began in the Doha Round negotiations over Trade-Related Aspects of Intellectual Property (TRIPS) and public health, in which India, South Africa, Brazil, and China acted as part of a single bloc to press the United States to better accommodate the interests of developing countries in providing generic therapies for the poor. In 2009 the bloc became institutionalized with the formation of the BASIC group, to act jointly at the United Nations Climate Change Conference. Inter-BRICS health cooperation gained further momentum two years later, when health ministers held their first meeting in Beijing, committing themselves to using the platform as a ‘forum of co-ordination, cooperation and consultation on relevant matters related to global public health’ (BRICS Health Ministers 2011). The theme of the first meeting was ‘Global Health—Access to Medicine.’ Since then BRICS countries’ health ministers have met annually, focusing on advancing inter-BRICS cooperation over issues such as emerging health threats, AIDS, tuberculosis, and non-communicable diseases (NCDs). Since 2012 the BRICS countries have also met on an annual basis at the World Health Assembly (WHA). At the sixty-sixth WHA, for example, they agreed to identify national institutions that could collaborate with WHO in developing a monitoring framework to help track progress toward universal health coverage (UHC) (McKee et al. 2014). Other institutions formed by BRICS countries may not have a direct bearing on GHG, but they suggest emerging powers’ financial contributions to global health is shifting from rhetoric to institutional reality. In 2013 BRICS leaders agreed to set up a new BRICS financing instrument to complement, if not compete with, the existing efforts of multilateral and regional financial institutions for global growth and development. Entering into force in July 2015, the New Development Bank has an initial contingent reserve arrangement of US$100 billion. The following year, China launched the Asian Infrastructure Investment Bank (AIIB) to address needs across Asia. As a new multilateral

Emerging Powers and Global Health Governance   305 financial institution, AIIB includes as members almost all emerging economies, which wield at least 50 per cent of the voting power. Its funding priorities include environmental protection and water supply and sanitation. In addition to these institutional arrangements, BRICS countries are also establishing global and regional health networks. Russia, for example, has been involved in healthrelated discussions in the Asia-Pacific area through the Shanghai Cooperation Organization and the Health Working Group of the Asia-Pacific Economic Cooperation (APEC) forum. Brazil and South Africa are participants in the Oslo Ministerial Group on Foreign Policy and Global Health, a club that aims to keep global health on the UN General Assembly agenda. Brazil has also been proactive in establishing cooperation among Lusophone countries, and with India and South Africa, through the India-BrazilSouth Africa (IBSA) Dialogue Forum, to address, among other things, health-related issues and concerns. In 2004 Brazil initiated the South-South Ties Network (Laços SulSul), which supports actions to prevent and control HIV/AIDS in eight Portuguese- or Spanish-speaking countries (Brazil, Cape Verde, Guinea Bissau, Sao Tome and Principe, East Timor, Nicaragua, Paraguay, and Bolivia) (Office of the UNICEF Representative to Brazil 2016). China uses its connection with ASEAN to support technical training for professionals from ASEAN member states. In 2013 it kicked off the ‘Belt and Road’ ­initiative, a development strategy that focuses on connectivity and cooperation among countries. At a national meeting on health, Chinese president Xi Jinping vowed to engage in global health, including strengthening health cooperation with countries in areas affected by the initiative (Zhang 2016).

The Effectiveness of the Institutional Involvement How does the institutional involvement of BRICS countries’ influence agenda setting and norm development in GHG? They span several continents and important regional groups and theoretically could push to have their health agendas included at all the high-level policy forums in which they participate, such as those of the UN agencies (e.g., WHO) and PSIs (e.g., G20). It could also be argued that emerging economies as a group fill an institutional vacuum that has been left by existing international agencies or institutions. As Kirton, Kulik, and Bracht (2014) indicate, the lack of G8 and G20 leadership in GHG only highlights the importance of contributions made by the BRICS countries. When WHO, the designated coordinating body for international health cooperation, is constrained by funding and management issues, then sidestepped by other international entities such as the World Bank as a result, BRICS countries’ foray into global health can be viewed as a potential solution to this institutional gap. In the meantime, their emergence as a new set of state players in GHG may lead to further duplication of resources in the absence of effective coordination with other global health actors and funders (Ruger and Yach 2005). As a group, BRICS countries can fill the leadership gap

306   Yanzhong Huang by focusing on areas WHO is unable or unwilling to address, such as pushing for more effective WHO reform and promoting universal access to medicines. As far as agenda setting and norm development are concerned, evidence suggests BRICS countries have historically not shown strong interest in being issue leaders. Scholars pointed out that BRICS countries did not officially engage in the thematic consultation on health when setting the post-2015 sustainable development agenda (Harmer and Buse  2014). Brazil, often considered the most active among emerging powers in conducting health diplomacy, has not yet used its role in international institutions such as the G20 and BRICS to promote health issues (Kirton, Kulik, and Bracht 2014). Leading emerging powers may host PSIs, but they often fail to use the current window of opportunity to champion global health. For example, there was little reference to health at the Durban BRICS Summit, indicating that South Africa’s global influence has been limited mostly to domestic issues (Kirton, Kulik, and Bracht 2014). Similarly, while the G20 Summit hosted by China in 2016 highlighted the country’s role as an agenda setter in global governance, global health overall was not addressed as a priority concern. Indeed, prior to the summit, the eighteen-page document outlining China’s G20 plan did not mention health at all (Huang 2016b). This lack of global health leadership may have something to do with the fact that BRICS countries are not particularly well represented in the governing bodies of major global-health-related institutions. As of June 2017, while WHO was headed by a Chinese national (who stepped down on July 1), other organizations, including UNICEF, UNAIDS, and the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund), rarely had representatives from emerging economies either serving in executive positions or chairing (or co-chairing) the governing bodies. That said, in some specific areas BRICS countries were able to play a leadership role in agenda setting. For example, Brazil was instrumental in raising the profile of the social determinants of health on the WHO reform agenda (Gautier et al. 2014), India was successful in pushing the WHA and the UNGA (United Nations General Assembly) to approve a resolution to develop a common action plan addressing mental health (Dhar 2012), and Russia displayed leadership in supporting the inclusion of NCDs on the global health agenda (Bliss 2013). Emerging powers have also shown a willingness to work with other global health actors in setting global health rules and norms. According to Lee, Chagas, and Novotny (2010), Brazil showed soft-power leadership in the negotiation of the Framework Convention on Tobacco Control (FCTC), which has been viewed as a prototypical example of health diplomacy. Despite resistance from its significant state-owned tobacco industry, China was considered the least vigorous opponent among the ‘big four’ (China, Japan, Germany, and the United States) during the development of the treaty. A staunch defender of state sovereignty, China showed flexibility in revising the International Health Regulations (IHR) so that WHO could use information from nonstate actors in decision-making. Similarly, although India was less proactive in its participation in the IHR revision process, it has played a constructive role in the development of other international norms, most notably the FCTC, TRIPS and public health, and the Pandemic Influenza Preparedness Framework (Huang 2013).

Emerging Powers and Global Health Governance   307 Equally important, BRICS countries have made important advances in implementing groundbreaking health regulations with global implications. They have contributed significantly to global commitments to AIDS treatment by being the first developing countries to offer free and universal access to antiretroviral treatments for people living with HIV/AIDS (Nunn et al. 2009). In 2012 Brazil became the first country to ban all ­flavours and additives in tobacco products. In 2016 it launched the first BRICS regional tobacco industry observatory. Developed and managed by Fiocruz and the Centre for Studies on Tobacco and Health, the observatory collects and shares information about tobacco industry strategies seeking to undermine tobacco control (Framework Convention Alliance 2016). To the extent that Brazil is a world leader in access to AIDS treatment and domestic tobacco control, China serves as an exemplar for compliance with IHRs. In the wake of the Severe Acute Respiratory Syndrome (SARS) outbreak of 2002–03, China not only amended its domestic laws and regulations but also dramatically improved core surveillance and response capacities to tackle public health emergencies. By 2008 it had built the largest infectious disease surveillance and reporting system in the world. The central government is today more responsive to transnational public health emergencies and has cooperated with WHO and the scientific community to strengthen early warning and surveillance activities of the Global Outbreak Alert and Response Network (GOARN). This is not to overlook that this emerging power’s compliance with international health rules is not always rosy or consistent. In contrast to Brazil and India, for example, the powerful tobacco industry continues to hinder Chinese efforts to comply with FCTC provisions. Indeed, among emerging powers, China’s anti-tobacco policies are deemed among the weakest and least effective in the world (University of Waterloo 2015). Analysis to date shows that BRICS nations influence GHG by being involved in global health institutions as a bloc or as individual countries anchoring other coalitions. While joint actions remain relatively rare, their cooperation during the Doha Round was critical to the adoption of a declaration on TRIPS and public health as well as paragraph 6 decision, which offered much-needed clarification of the relationship between public health protection and commercial interests (‘t Hoen 2002). In 2005 Brazil successfully allied with eleven Latin American governments to reach an agreement with twenty-six pharmaceutical companies to lower the prices of HIV/AIDS drugs in the region (Okie 2006). Working together, BRICS countries were also successful in establishing new institutions at WHO, such as the Ethics Committee to deal with nonstate actors’ participation (Gautier et al. 2014). Of course it is one thing to get together and issue policy statements with a common vision; it is another to translate them into concrete policy action. In reforming WHO, BRICS countries articulate a vision of WHO as an organization with a broad mandate delivered with sufficient and predictable funding. In doing so, however, they do ‘not coordinate or cooperate to take joint actions or proposals’ (Gautier et al. 2014). The strength and influence of the cooperation within the emerging powers depends on their ability to walk the talk. Unfortunately, even with the presence of numerous institutions and fora for them to participate in, evidence so far suggests differences in their foreign

308   Yanzhong Huang policy may prevent them from developing a coordinated approach to global health (Bliss, Buss, and Rosenberg 2012). In May 2017, for example, India boycotted China’s first Belt and Road Forum to show displeasure over China’s failure to respect India’s ‘sovereignty and territorial integrity’ in the China-Pakistan Economic Corridor (which passes through what India considers its own territory) (Financial Express 2017).

Material Capabilities Development Assistance for Health In terms of the material capabilities BRICS countries can mobilize for global health, their growing ability to provide DAH stands out. Although most emerging economies have been long-standing recipients of foreign aid, they have also had a long history of providing development assistance. Russia and Brazil started their foreign assistance programmes—of which health was a focus—around six decades ago (Harmer, Xiao, Missoni, and Tediosi 2013). China’s DAH is traced back to the dispatch of medical teams to Algeria in 1963. In health-related development assistance, the preferred channel varies from bilateral (India, China, South Africa), to trilateral (Brazil), to multilateral (Russia). In the past decade, growing economic strength has enabled most of the emerging economies to move away from net recipient status to net donor status. China is making steady progress toward fully becoming a donor. In Africa the growing demand for resources and markets, as well as its efforts to expand its influence on the continent, intensified China’s competition with Organisation for Economic Co-operation and Development (OECD) donors, such as Japan, driving up the level of foreign aid to the continent (Huang 2014; Xie 2013). As early as 2007, in recognition of its role in offering overseas development assistance, the World Bank’s International Development Association included China as a donor. The shift to a net donor was also the result of its decline as a recipient of foreign aid. In 2010 China received US$646 million as foreign aid, or approximately 0.01 per cent of its gross national income (GNI) (Development Initiatives 2012). The change is clear in China’s health sector: in 2011 the Global Fund announced that China would no longer be eligible to apply for funding. By the end of 2012 all bilateral programmes aimed at supporting China’s health sector ceased to exist. India and Brazil soon followed China’s in this process. Between 1967 and 2010 net official development assistance received as a percentage of GNI in India dropped from 2.79 to 0.17 (World Bank Group  2016). A data crosscheck by Le Monde Diplomatique Brasilthe found that Brazil offered more international assistance than it received from countries and multilateral agencies between 2005 and 2009 (Apolinario 2016). Indeed, official development assistance that Brazil provided doubled between 2007 and 2008 and tripled from 2009 to 2010 (Frayssinet 2011). Due to the lack of systematic, internationally comparable data on their aid activities, tracking flows of DAH provided by BRICS countries is not an easy job (Fan et al. 2014). The difficulty of quantifying their DAH levels is compounded by the fact that ‘such aid is

Emerging Powers and Global Health Governance   309 not solely financial but also includes much sharing and exchange of resources, technology and knowledge’ (Kickbusch  2014, 464). The limited data available do suggest the ­expansion of their DAH programmes. Since the 1990s China has diversified its aid by investing increasingly in health-related infrastructure and human resources. By the end of 2011 it had built one hundred fully stocked hospitals in fifty-two countries, while holding more than four hundred training courses for fifteen thousand foreign healthcare personnel (Chen and Ji 2012; Wen 2009; Information Office 2012; and Embassy of the People’s Republic of China in the United States of America 2012).1 China’s health grants to Africa reached US$3.8 billion during the five-year period between 2009 and 2013, which represented a 146 per cent increase over the five-year period between 2004 and 2008 (Shajalai et al. 2017). In 2014, during the Ebola outbreak in West Africa, China kicked off its largest ever response to an international humanitarian crisis, offering US$123 million worth of humanitarian aid to the global Ebola control efforts (Huang 2017a). Similar to China, much of India’s DAH takes the form of health infrastructure development, although it has also dispensed significant resources, donating medicines, diagnostics, ambulances, and other supplies to recipient countries. Since 2009 India has committed at least US$100 million to bilateral health projects in nearly twenty countries in Africa and South and Southeast Asia (Tytel and Callahan 2012). While economic strength is often used to justify calls for emerging powers to engage more fully as global health donors, domestic health and political conditions in each country ‘exert a profound influence on how each one’s global health outreach is structured and publicized’ (Bliss 2010, 2). While it’s true that in these countries hundreds of millions of people have been lifted out of poverty, and considerable progress has been made toward achieving the Millennium Development Goals and UHC, they still must confront numerous public health challenges. Each year half of the 8.6 million people who develop tuberculosis are found in BRICS countries, not to mention the continuously growing burden of NCDs (Creswell et al. 2014; Huang 2011). The WHO estimate for deaths caused by NCDs increased by more than 25 per cent in four BRICS countries (Brazil, India, China, and South Africa) (Jakovljevic and Milovanovic 2015). Combined, BRICS countries account for about 40 per cent of the global disease burden, measured by disability-adjusted life years lost (Department of Health Statistics and Informatics 2008). Additional public health challenges include poverty, health inequity, malnutrition, tobacco use, and poor public hygiene standards. The progress toward UHC is highly uneven across BRICS countries. In 2014, 63 per cent of health spending in India was out of pocket, compared with 46 per cent in Russia, 32 per cent in China, 25 per cent in Brazil, and 6 per cent in South Africa (IndexMundi 2015). These challenges suggest a fundamental capacity gap within emerging powers in protecting and promoting the health of their own populations. This capacity gap, in turn, limits these nations’ capacity to earmark significantly more resources for health needs in other, poorer countries. The internally focused nature of Chinese health policy was indicated by a senior Chinese official, who stated that ‘in order for China to shoulder more global health responsibilities, the most important thing is to take care of its own business; taking care of China’s health care is itself the biggest contribution to world health’ (Huang  2013). It is difficult to dispute China’s

310   Yanzhong Huang domestic contribution to global health improvement; in part because of its high hospital delivery rate, China accounted for over one-quarter of the reduction in infant mortality worldwide during 1990–2012 (Huang 2017b). Thus, while many emerging economies have ramped up DAH, from emerging economies it remains minuscule compared to that from traditional OECD donors. About 60 per cent of US aid in Africa, for example, goes to health-related programmes alone (Brautigam 2011). By contrast, the health component only accounts for 25 per cent of Russia’s foreign aid and 17 per cent of Brazil’s (Harmer et al. 2013). China’s annual spending on global health is about $200 to $300 million, far less than US government funding for global health (about $10 billion) (Valentine, Wexler, and Kates 2016). During the Ebola outbreak in West Africa, four BRICS countries (without South Africa) combined contributed to only 2.5 per cent of the UN’s main Ebola relief fund, compared with 45 per cent from the United States (Financial Tracking Service 2017). Also, until recently BRICS countries have not significantly stepped up their financial commitments to global health institutions such as the Global Fund and the GAVI Alliance (Kickbusch 2014). In 2012 the BRICS provided only 3.1 per cent of total WHO contributions (assessed and voluntary) (Gautier et al. 2014). Studies suggest limited financial resources also explain why emerging economies have targeted their DAH more selectively and strategically. As Harmer and Buse (2014, 12) note, in terms of DAH from BRICS nations, ‘it is not the size of a country’s material capability that ultimately matters; it is how that capacity is put to best use’. BRICS countries prefer to leverage areas in which they maintain a comparative advantage, which involves a combination of raw materials, technical capacity, manufacturing conditions, and new markets. Examples include Brazil promoting cooperation with Lusophone countries (e.g., East Timor, Mozambique, Angola, and Guinea-Bissau) to strengthen health education, technical assistance, and research; China investing in hospitals and antimalarial clinics as part of its strong interest in infrastructure development as well as its success in developing antimalarial drugs; and India taking advantage of its information and communications technology to connect to hospitals and universities in Western Africa to facilitate an information exchange of best practices through the Pan-African e-Network. There are certainly exceptions. Russia has one of the highest ratios of health workers per capita, but it has less interest in practicing medical internationalism (i.e., sending medical professionals to serve in other countries) than does China (Harmer and Buse 2014). By contrast, China has a low ratio of health workers (Encyclopedia of the Nations 2005), but it has sent a total of more than twenty-three thousand medical workers to sixty-seven countries and regions. In 2015 alone China had fifty-two medical teams stationed in fifty-one countries. As far as motivations behind DAH are concerned, studies undertaken to date show that foreign policy and development goals have been strong underlying forces driving the emerging powers’ DAH agendas. In terms of regional priorities, DAH has been focused on neighbor countries. The need to assuage the fears of its Asian neighbors has led China to concentrate DAH in East and Southeast Asia, aside from Africa. India’s DAH is directed primarily toward its proximate neighbors, namely Bhutan and Nepal. Anxiety over Afghanistan’s relationship with Pakistan was a critical factor in leading India to

Emerging Powers and Global Health Governance   311 become a major supporter of reconstruction in Afghanistan, which has received most of India’s DAH since 2002. Driven by interest in expanding regional influence, South Africa earmarked 95 per cent of its foreign assistance (in the form of grants or technical support) to other African countries (New African Magazine 2012). Brazil worked with countries in the Union of South American Countries to improve access to healthcare services, strengthen health and environmental surveillance, and eliminate specific diseases such as onchocersiasis. Over the past decade most of BRICS countries’ global health outreach has been increasingly directed toward Africa. One of the few exceptions is Russia, whose geopolitical concerns explain why its limited bilateral assistance was almost exclusively focused on the Commonwealth of Independent States or the ‘near abroad’. In addition to foreign policy considerations, DAH programmes have been increasingly driven by economic policy. In both China and India it has been widely observed that DAH has advanced domestic economic interests, including accessing natural resources and enhancing market access for domestic pharmaceutical industries (Huang 2013). It has been noted that India appears as a donor in another country ‘only when it is also an investor, trade partner or political ally, or can become one’ (Jobelius 2007). This practice of using DAH for promoting exports is occurring at a time when traditional donors have moved away from tied aid (Brautigam 2009).

Leading Manufacturers of Low-Cost Medicine Aside from DAH, emerging economies have contributed to GHG by leading in the manufacture of low-cost medicines and vaccines. One of the weaknesses of existing GHG is the institutional inability to ensure universal access to low-cost medicines. While perceptions may vary about the causes of such deficiency, some leading global health scholars focus on the technical aspect of the problem and call for mechanisms to generate and apply new knowledge or technical interventions.2 In that sense, BRICS countries’ advancement in the pharmaceutical sector has profound implications for GHG, especially in terms of its potential to open up access to affordable life-saving drugs. Brazil, China, and India have led these efforts through trade and investment. With a significant generic drug industry, Brazil has invested in establishing combination therapy ARV production centers in Mozambique and Angola. South Africa, home to regional manufacturing and distribution centers for many global pharmaceutical firms, has accounted for more than 70 per cent of sub-Saharan Africa’s annual pharmaceutical production. The Biovac Institute, the largest distributor of vaccines in South Africa, not only supplies all eight of the vaccines that comprise the country’s Expanded Programme of Immunization, but also supplies vaccines to Namibia, Botswana, and Swaziland (New African Magazine 2012). A more prominent example is India. Today, India supplies 80 per cent of all donor-funded HIV therapies in the developing world. It is also the largest provider of cheap, high-quality vaccines for developing countries, manufacturing

312   Yanzhong Huang 60–80 per cent of all vaccines procured by UN agencies (Green 2011). Indian pharmaceutical firms have also invested in drug production in Africa and Latin America (Morrison and Kates 2006). In this way, India has played a pivotal role in driving down prices and improving access to vaccines and life-saving drugs for millions worldwide. China’s role in ensuring affordable access to medicines globally is more indirect but equally significant. With an annual output of 800,000 tons of pharmaceutical ingredients, China is a world leader in producing active pharmaceutical ingredients (APIs). Its ability to produce and supply APIs is of critical importance to the global generic drug market, as well as to formulators in emerging economies (e.g., India and Brazil) and the developed world. Tapping into China’s low-cost, skilled labor, contract research organizations (CROs) have proliferated in China, providing preclinical and clinical research services to multinational pharmaceuticals. Pharmaceutical molecularization creates additional opportunities for China to catch up technologically with industrialized countries in developing medical countermeasures efficiently and effectively to address major disease outbreaks. When ZMapp, the most promising treatment, was quickly exhausted in the fall of 2014, Chinese scientists used a different technology to produce one hundred doses of biosimilar (MIL-77) within three months. The drug was reported to have successfully treated a British military nurse who contracted Ebola while serving in Sierra Leone (Khomami 2015).

Competing Visions To the extent that the absolute size of emerging powers’ material capabilities is much smaller than those of OECD countries, other sources of influence are important to understand. Of particular note are ideational factors such as perceptions, ideas, values, and identities. A look at the public statements at the annual BRICS Health Ministers’ Meetings revealed that the health issues they considered a priority are not dissimilar to those examined at any global health conference or meeting. Nevertheless, some of the issues that are consistently alluded to by BRICS nations (e.g., NCDs, access to affordable medicines) are ones that the G8 and OECD have long ignored (Harmer and Buse 2014). Underpinning emerging powers’ engagement in global-health-related institutions and their experience in providing DAH is a set of values, principles, and priorities that are different from the dominant OECD health development paradigm.

An Alternative Model of DAH? The growing role of emerging powers appears to be leading to a reshaping of the landscape of global health cooperation, in part because the nature and modalities of their foreign aid programmes are different from those of traditional donors. Positioning themselves as ‘development partners’ rather than aid donors, they emphasize cooperation

Emerging Powers and Global Health Governance   313 between developing countries (Acharya et al. 2014). In contrast with donor-driven initiatives, their assistance programmes are primarily ‘demand driven’ or ‘request based’. Instead of announcing DAH initiatives, then publishing formal requests for proposals (RFPs), potential recipients approach the donor for development assistance. The overall pattern of investing in specific, country-based projects also contrasts with Western donors, which tend to make large programmatic investments that involve multiple projects (e.g., the US President’s Emergency Plan for AIDS Relief, or PEPFAR). In addition, China, India, and South Africa deliver DAH primarily on a bilateral basis, rather than in collaboration with additional countries or international institutions. For example, China sponsored nineteen antimalarial projects in Africa between 1978 and 2008, but none coordinated its work with global antimalarial projects (Huang 2013). In November 2014, during the Ebola outbreak, China conducted a clinical case series to test an experimental anti-Ebola drug called favipiravir in Sierra Leone, but it did so without informing third parties like Doctors Without Borders (MSF), which was planning to test the very same drug in Guinea in December. This lack of collaboration with other donors clearly signals a desire by China to maintain its independence and thus independent control over its DAH policies. However, it is seen as a missed opportunity to draw strong conclusions on the drug, as the two projects used incompatible methodologies (Huang 2017c). Analysis to date describes these distinctive DAH models as a reflection of a general rejection of existing Western approaches to development assistance. Most emerging powers do not look favourably on the donor-recipient paradigm by which the wealthy choose to give handouts to the poor. They prefer a new paradigm in development cooperation, driven by mutual interests, founded on shared accountability and leadership from recipient countries, and characterized by innovative approaches based on recipients’ own development experience. These countries appear to have little interest in attaching overt political strings to foreign aid. As a result, their programmes are beginning to run in direct competition with those of traditional donors who emphasize accompanying conditionalities, for example, for ‘good governance’ and human rights. In 2011 China even declared that ‘the principle of transparency . . . should not be seen as a standard for South-South cooperation.’ India goes as far as to openly reject paternalistic development terms such as ‘donor’ and ‘aid’, preferring to view its  development assistance programmes as a South-South partnership (Tytel and Callahan 2012).

A State-Centric Approach to International Health Cooperation Another competing vision of GHG concerns the role of the state. Although BRICS countries register a desire for an alternative model for GHG, they continue to stress the importance of Westphalian norms of state sovereignty and noninterference, and

314   Yanzhong Huang some also discourage the participation of nonstate actors. The IHR negotiations ­provide a useful example for examining state centrism. Prior to regional consultations and intergovernmental working group (IGWG) negotiations, China and India declined to gather input from local non-governmental organizations (NGOs) and even sought to limit their role (Kamradt-Scott, Lee, and Xu 2013). At the same time, sovereignty concerns led China to oppose a move to recognize Taiwan’s status at the WHA. Keenly aware that the principle of ‘universal application’ to the IHR might be used by Taiwan to justify formal WHO membership, China’s chief negotiator contended that ‘health is a very important issue, but sovereignty and territorial integrity are more important’ (Sha 2004). China later softened its stance and allowed Taiwan to obtain special observer status at the WHA, granted on an annual basis. However, Taiwan is still not permitted to liaise with WHO other than with its headquarters in Geneva. Later, after the proindependence government of Tsai Ing-wen was elected and the Taiwanese government no longer accepted the ‘One China’ principle, China withdrew its support for Taiwan’s WHA observer status. A state-centric approach is also evidenced in the approach to WHO reform by emerging powers. As an international organization established after World War II, WHO is a member-state-run organization in which every country has a vote in its plenary decision-making body (i.e., the WHA). While many emerging powers favour conducting DAH on a bilateral basis, BRICS nations in the context of reforming WHO are committed to strengthening and legitimizing WHO through the principle of multilateralism (BRICS Ministry of External Relations 2012). But many argue that member states, which help shape WHO’s priorities and thus the Secretariat’s mandate, are also to blame for not providing the Secretariat with the necessary authority and resources to push meaningful reforms forward (Huang  2016a). Paradoxically, perhaps, BRICS countries favour strengthening the power of member states rather than broadening membership to include nonstate actors. Some BRICS countries (Brazil, India, and South Africa) might be supportive of the involvement of nonstate actors, but they have been reluctant to involve the corporate sector and influential private foundations in WHO decision-making (Gautier et al. 2014). This contrasts with the position of countries in Europe and America, which support multi-stakeholder participation in GHG. Furthermore, in working with external actors (e.g., NGOs and intergovernmental organizations) on domestic health projects, emerging economies are conscious of not allowing external actors’ views to prevail. Believing in its own ability to handle domestic health needs, for example, the Indian government has increasingly taken control over the anti-polio campaign at home. Russia and China took a similar approach to the activities of the Global Fund domestically. A key element of the Global Fund partnership is the Country Coordinating Mechanism (CCM), which includes representatives from government, the private sector, technical partners, civil society, and patient communities. Nevertheless, the idea of a CCM has never been internalized by the governments of Russia and China. In 2009 Russia decided not to apply for Global Fund grants. Studies show that the government’s refusal to fund harm reduction resulted in a surge in new HIV/AIDS infection rates, in contrast with global trends (Bennett and Kravchenko 2014).

Emerging Powers and Global Health Governance   315 State dominance has also been strong in China (Kamradt-Scott, Lee, and Xu 2013)—indeed, China was the only country among Fund-recipient countries that saw the domination of government health authorities at CCM, principal recipient (PR), and sub-recipient (SR) levels. Right after the departure of the Global Fund, China CCM was quietly and quickly replaced by a government committee that excluded the participation of civil society organizations (CSOs) (Khan 2014). The state-centric approach to DAH of emerging economies is out of step with the recognition of growing transnational health challenges, which demand collective action transcending the narrowly defined concept of sovereignty as autonomy and the rise of a complex web of transgovernmental networks characterized by an intensified exchange among various global health actors, including nation-states, international governmental organizations, public-private partnerships, and nonstate actors (Slaughter 2004). When participating in discussions to strengthen the Biological Weapons Convention, for example, China, India, and Russia teamed up with Cuba, Iran, and Pakistan to articulate a common opinion on the exceptional role of states and blocked references to the need for improving transparency (Huang 2013). In later meetings, they pushed for a return to negotiations on a verification protocol, at a time when nonstate actors and bioterrorism had become an increasingly serious concern.

Domestic Health Model Due to their relatively large populations and the mounting public health and healthcare challenges they have to confront, BRICS countries serve as a reference point for other low- and middle-income countries (LMICs). Historically China and India, through their experience of primary healthcare (PHC), demonstrated the capacity to improve basic health indicators despite limited resources. This contributed to the rise of the PHC movement in the late 1970s, embodied in the WHO Declaration of Alma Ata, agreed upon in 1978. Today they claim to have amassed a wealth of experience in coping with health needs in resource-limited settings, from which other LMICs can draw valuable lessons. During the 2014 Ebola virus outbreak, for example, a Chinese scholar claimed that ‘China’s experience [in disease prevention and control] applies to the whole world’ (Zhu 2014). This appeared to be confirmed by reports suggesting that Liberia learned from Chinese experience in applying public health measures such as quarantine to facilitate control of the outbreak (Garrett 2015). Emerging powers have also contributed to debates concerning the goal of UHC, which former WHO Director-General Margaret Chan3 considered ‘the single most powerful concept that public health has to offer’. If successfully implemented in BRICS countries only, UHC would cover about half of the world’s poor. In recognition of health as a human right, Brazil has not only implemented a programme for universal access to ARV therapy, but also extended healthcare coverage to one hundred million people through a tax-financed national healthcare system and conditional cash transfer programme. This decision, seen by many as a success for progressive public health and healthcare

316   Yanzhong Huang approaches, received widespread international recognition and was cited as an example for other countries to follow (Kirton, Kulik, and Bracht 2014). China joined Brazil in the UHC movement in 2009, when it kicked off a new round of healthcare reforms to provide basic UHC to its population. By 2012 China had put in place a system of basic medical insurance that covers almost the entire population of nearly 1.4 billion people. Evidence suggests these efforts are paying off. China’s average life expectancy at birth had increased from 74.8 in 2010 to 76.1 by 2015, significantly higher than the world average of 71.4 and on a par with much of Eastern Europe. In developing a framework for providing affordable healthcare to its people, India is often described as practicing ‘frugal innovation’; that is, finding ‘the simplest and cheapest way of doing something without compromising effectiveness’ (Shetty 2012).4 In putting innovation to work, India’s business leaders and health providers have collaborated with government actors, private hospitals, and the information technology and telecommunications sectors. Some of the health-related innovations are the Aravind Eye Care System (which earns money from rich patients and uses that to subsidize poor patients, who receive low-cost or free care) and the LifeSpring Hospital System (a joint venture between the Acumen Fund and Hindustan Latex to provide reproductive and pediatric care to low-income urban mothers and their children) (Ruger and Ng 2010). In 2000 Dr Devi Shetty founded Narayana Hrudalaya (NH) in Bangalore. By embracing mass production, he is able to make quality healthcare financially accessible to a wider range of people. As a result of Shetty’s innovation, India is on course to become the first country in the world to delink health from wealth. But the experience of BRICS countries’ domestic health development is by no means an unproblematic example that others can follow. In addition to the high risk of infectious disease and the looming threat of NCDs, these countries are still struggling with the challenge of finding an effective model to provide quality and affordable healthcare to their huge populations. While India’s healthcare system is plagued by a lack of infrastructure and inefficient workforce (Thakur et al. 2017), Brazil’s system is facing sustainability problems due to misused resources, political upheaval, and a funding crisis. Theoretically, China’s rapid economic development should create fertile ground for innovative ideas to achieve UHC. According to some analysts, China’s development model emphasizes a country’s own characteristics (as opposed to a one-size-fits-all model), with willingness to innovate and experiment (Cooper Ramo 2004). However, this philosophy, also known as the ‘Beijing Consensus’, has not led to significant innovations in healthcare reform. Many of the ideas put forth by Chinese policymakers are not novel. The widely acclaimed new cooperative medical scheme covers nearly the entire rural population of China, but it is simply a revival of the Maoist Cooperative Medical Schemes. Chinese healthcare reform has also fallen increasingly under the sway of Western healthcare models. Since the beginning, debates about reform have centred on whether to adopt a government-focused approach inspired by the British model, in which the government provides basic healthcare for free, or a market-focused approach influenced by the German model, which favours the use of third parties to provide health services. In terms of the impact of ideas and visions for GHG, BRICS nations’

Emerging Powers and Global Health Governance   317 domestic healthcare models remain under the sway of Western countries, rather than the other way round.

Discussion The analysis of institutions, material capabilities, and vision of BRICS countries helps us gain a better understanding of the past, present, and future roles assumed by emerging powers in GHG. Despite the BRICS nations’ long history of providing DAH, it was only in the beginning of this century that they shifted toward net donor status. During the same period BRICS countries also expanded their engagement in GHG to areas of agenda setting and norm development. To be sure, their contributions to GHG remain limited and constrained by domestic health challenges and institutional shortfalls, and as a group they have only occasionally spoken in a single voice, let alone acted jointly upon their policy declarations. But all this has not prevented them from playing a distinctive, important, and even inspiring role in GHG. Their unique DAH patterns, their status as leading manufacturers of affordable drugs, and a state-centric approach to international health cooperation all suggest their ability to present an alternative to the existing GHG paradigm. The analysis nevertheless has not led us to conclude with confidence that BRICS countries represent a transformative force in GHG. A thorough understanding of their role in GHG requires us to collect additional data to explore the incentives and capabilities of their involvement. While this chapter touches on the issue of incentives when discussing the BRICS nations’ growing efforts to provide DAH, it has not fully addressed the issue of why they have become more proactive in engaging broader GHG issues over the past decade or two, and why they are reluctant to work together as a group. Furthermore, to gauge their commitments to and implications for GHG, we need not only systematic and internationally comparable data but also fuller mapping of their global health initiatives. What are the actual levels of their DAH, and how do their global health activities complement or conflict with existing global health projects and initiatives? The AidData (2017) portal, which provides access to development finance activities from 1945 to the present, may enable us to track under-reported flows of DAH provided by emerging powers.5 As far as their roles in global health institution building and norm development are concerned, only through tedious archival research and semistructured interviews with the ‘insiders’ can we get a clear idea. The qualitative research method would be particularly helpful in addressing questions including, but not limited to, the following: How do emerging powers reconcile state-centrism with the requirements of globalization? How do they balance their emphasis in traditional global health-related institutions such as UN agencies and their growing interest in new institutions such as G20? Why are they keen on strengthening WHO through multilateralism despite their preference for bilateral DAH? How do the differences and tensions within the group affect their willingness and effectiveness in participating in GHG? Our

318   Yanzhong Huang knowledge of emerging powers’ role in GHG will remain limited if we do not have satisfactory answers to these questions.

Conclusion An examination of BRICS countries’ vision, institutions, influence, and material capabilities shows the distinctive and positive role emerging powers can play in GHG. First, in addition to existing domestic and international institutions, they are beginning to establish their own stand-alone institutional structures in engaging global health. While they have been laggards in some areas of global health agenda setting and norm development, they have been active, and even taken on leadership roles, in many others. Second, they have expanded their DAH programmes, which should contribute to health system strengthening and improve people’s health in recipient countries. Also, the pharmaceutical industry in these countries has redefined affordable drugs, dramatically improving access to medicines for the world’s poor. Third, their approaches in conducting health diplomacy, including providing DAH as well as addressing domestic health challenges, have enriched the ideational foundations of GHG, pointing to an alternative model for improving global health. Compared with those of OECD countries, BRICS countries’ DAH programmes are not so much about financial contributions as about using the limited DAH as a way to empower recipient countries through international cooperation. This finding has important implications for emerging powers’ ability to engage global health even when their economies are slowing down. That said, their roles in GHG remain generally limited, and it is still too early to view them as a counterbalance or counterforce to industrialized countries in GHG. The DAH from emerging powers remains dwarfed in comparison to traditional OECD donors. Their distinctive patterns of DAH do not align well with many existing global health initiatives and projects, which may create additional silos and exacerbate coordination and coherence problems in GHG. Furthermore, as the DAH policy structure remains conditioned by the BRICS countries’ domestic health agendas, it would be unrealistic to expect them to significantly increase their DAH anytime soon, and global health financing will continue to rely primarily on the largesse of the OECD countries. In developing and participating in global-health-related institutions, their approach remains selective and individualistic, and they have only occasionally played the leadership role in agenda setting and norm development. Despite the rhetoric of South-South solidarity and efforts to form coordinated positions, it remains to be seen if they will develop the ability to translate policy statements into actions. A look at the ideational foundations of BRICS nations’ involvement in GHG suggests that while they have an alternative model for GHG, most components of the model are neither novel nor innovative, and their effectiveness remains in question. Their efforts to promote global health agenda such as UHC and global health security may offer both positive and negative lessons for other LMICs, but they primarily serve their domestic

Emerging Powers and Global Health Governance   319 interests as opposed to exhibiting a genuine concern for improving global health. Also, a state-centric approach to global health often leads to a narrow and limited interaction with GHG, thereby reducing the scope and effectiveness of international cooperation in an era of interdependence. Overall, not only do emerging countries fail to shoulder significantly more responsibilities in GHG, but their GHG-related policies and practices also fail to provide a viable, sustainable alternative to the dominant global governance framework. These findings may shed some light on future international cooperation and GHG. Emerging powers have huge unrealized potential in GHG and need to be encouraged to do more. But the future directions and effectiveness of their participation will ultimately be determined by the dynamics of the ongoing global power shift and their ability to address domestic health challenges. It is critical to urge them to shoulder greater global health responsibilities, but it is equally important to accommodate their legitimate domestic development concerns while including them in the governance structure as equals. This would eventually require a restructuring of the existing power structure of GHG so that these countries have a larger say in the global health agenda.

Notes 1. From 1956 to 1999, China had helped build only twenty hospitals in Africa. 2. See, for example, Moon (2008); Sandberg, Andresen, and Bjune (2010); and Denburg and Lee (2013). For a discussion of the different perspectives on the shortfalls of GHG, see Lee and Kamradt-Scott (2014). 3. http://www.who.int/dg/speeches/2012/wha_20120521/en/. 4. See also ‘First Break All the Rules’ (The Economist 2010). 5. For an example of using the data, see Grépin et al. (2014).

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Further Reading Cox, Robert W. 1996. Approaches to World Order. Cambridge, MA: Harvard University Press. Denburg, Avram and Kelley Lee. 2013. ‘Access to Paediatric Medicines: The Global Political Economy of Paediatric Drugs for Children in the Developing World.’ In Global Governance of HIV/AIDS: Intellectual Property and Access to Essential Medicines, edited by Obijiofor Aginam, John Harrington, and Peter K. Yu, 53–81. London: Edward Elgar. Lee, Kelley, and Adam Kamradt-Scott. 2014. ‘The Multiple Meanings of Global Health Governance: A Call for Conceptual Clarity.’ Globalization and Health 10 (1): 28. Moon, Suerie. 2008. ‘Medicines as Global Public Goods: The Governance of Technological Innovation in the New Era of Global Health.’ Global Health Governance 2 (2): 1–23. http:// www.ghgj.org/Moon_Medicines%20as%20Global%20Public%20Goods.pdf. Sandberg, Kristin Ingstad, Steinar Andresen, and Gunnar Bjune. 2010. ‘A New Approach to Global Health Institutions? A Case Study of New Vaccine Introduction and the Formation of the GAVI Alliance.’ Social Science & Medicine 71 (7) (October): 1349–1356.

chapter 17

The Politics of Gl oba l H e a lth Agen da Set ti ng Stephanie L. Smith and Jeremy Shiffman

This chapter examines the politics of global health agenda setting, the process by which global health issues come to receive attention from actors that control or influence the allocation of financial, technical, human, and other kinds of resources. These actors include national governments and their citizens, international organizations, international non-governmental organizations (NGOs), private foundations, bilateral and multilateral donors, research institutions, industries, and the media. The politics of global health agenda setting deserve attention for several reasons. First, resources are limited, so only a small number of conditions attain high-level agenda status. Second, resource allocations often do not correspond closely with disease burden or the cost-effectiveness of interventions, suggesting that other factors—including political ones—shape the global health agenda. The global health agenda is set in a range of social and political venues. These differ in the kinds and amounts of resources they offer (Baumgartner and Jones 1993; Birkland 2007; Hilgartner and Bosk 1988; Kingdon 1995; Kirp 1982). Global decision-making bodies such as the United Nations General Assembly (UNGA), World Health Assembly (WHA), and United Nations Security Council (UNSC) make declarations and issue resolutions. International organizations such as the World Health Organization (WHO) issue guidelines, provide technical support, and facilitate treaty negotiations. Donors, including the United Kingdom (UK) Department for International Development (DFID) and the Bill and Melinda Gates Foundation (BMGF), allocate financial resources for research, initiatives, and programs. Leading media outlets, such as the New York Times and the Guardian, allocate publication space and signal to elites and

326   Stephanie L. Smith and Jeremy Shiffman publics which issues they ought to attend to. Research institutions produce scientific knowledge, which medical journals scrutinize (through the peer-review process) and disseminate. Professional associations set standards. Pharmaceutical companies invest in particular products. An issue may be put onto the agenda of one venue but not others. This chapter is organized around four categories of factors that shape global health agenda setting: actors, ideas, interests, and institutions. Actors refers to the decisions and behaviour of individuals and organizations. Ideas pertains to knowledge and principle-based concerns. Interests concerns individual agendas. Institutions pertains to rules and procedures, formal and informal, that structure the process. Key insights from the analysis, as well as other promising analytical frameworks and methodological approaches, are discussed in concluding remarks.

Actors WHO and member states dominated agenda setting processes for international health cooperation from the late 1940s until the 1980s, when the World Bank and other organizations also carved out prominent roles (Walt 1994; Walt, Spicer, and Buse 2009). A proliferation of individuals and organizations—both state and nonstate—now shape global health agenda setting. Among these individuals are policy entrepreneurs who draw attention to problems, link these to solutions, and take advantage of political opportunities (Kingdon 1995). Studies of multiple issues—including surgery, alcohol harm, cervical cancer, mental health, nutrition, family planning, maternal survival, and newborn survival—offer evidence that the ebbs and flows of attention are shaped by the absence, presence, and capabilities of such entrepreneurs (Schmitz 2016; Parkhurst and Vulimiri 2013; Reichenbach 2002; Shawar, Shiffman, and Spiegel 2015; Pelletier et al. 2012; Tomlinson and Lund 2012; Blanc and Tsui 2005; Smith and Rodriguez 2016; Shiffman 2016a). Leaders of extraordinary stature, such as heads of state and international organizations, are the targets of entrepreneurial efforts and sometimes become influential champions themselves. Such high-level leadership has made a significant difference for several global health issues. For example, former UN Children’s Fund (UNICEF) executive director James Grant led the Child Survival Revolution during the 1980s, culminating in the assembly at the World Summit for Children in 1990 of the largest group of world leaders in history to commit to improving child health and survival (UNICEF n.d.). UN Secretary General Kofi Annan championed the UN Millennium Declaration and Goals at the end of the twentieth century, setting in motion a new development ‘supernorm’ that mobilized action on several major global health issues over the following fifteen years (Fukuda-Parr and Hulme 2011). Subsequently, as part of efforts to accelerate progress on UN Millennium Development Goals 4 and 5 (on child and maternal survival), several world leaders, including the prime ministers of Norway, the UK, and Canada,

Politics of Global Health Agenda Setting   327 and UN Secretary General Ban Ki-moon, championed initiatives that drew some US$40 billion in financial commitments to improve women’s and children’s health between 2010 and 2015 (Smith and Rodriguez 2016). Individuals and organizations with shared concern for health issues often band together to form networks. There is evidence to suggest that adoption by networks and other gatekeepers is an essential step in the agenda setting process for many issues (Carpenter 2007; Carpenter et al. 2014; Shiffman, Beer, and Wu 2002). Networks vary in composition and cohesiveness, features that have implications for their agenda setting effectiveness. Homogeneous networks, such as those limited to technical experts from high-income countries, tend to lack advantages that more diverse groups have in problem-solving (Hong and Page 2004; Page 2007). Comparative studies of six global health networks found that networks forming broad political coalitions (tobacco, tuberculosis, and maternal health) were more effective in advancing their issues on the global health policy agenda than those that delayed expansion (childhood pneumonia and newborn health) or failed to diversify beyond a health-focused technical core (alcohol) (Gneiting and Schmitz 2016; Smith and Shiffman 2016; Berlan 2016; Quissell and Walt 2016; Shiffman et al. 2016). Studies of global health agenda setting for sexually transmitted infections and undernutrition have consistent findings, suggesting coalition building is facilitative, while insularity hinders network effectiveness (Lush, Walt, and Ogden 2003; Morris, Cogill, and Uauy 2008). Ogden, Walt, and Lush (2003) caution, however, that the insertion of political positions into technically oriented policy communities, as occurred in the case of DOTS (Directly Observed Treatment, Short Course) promotion as a means of controlling and treating tuberculosis, can cause internal contestation and fragmentation. Contestation over problem definition, priority interventions, and advocacy strategies can lead to fragmentation, limiting the effectiveness of networks seeking to advance issues on the global health policy agenda. Contestation over these issues has posed challenges for non-communicable diseases, maternal health, alcohol control, oral health, undernutrition, sexually transmitted infections, and health systems strengthening networks, making it difficult to articulate a clear message and present a united front (Benzian et al. 2011; Hafner and Shiffman 2013; Jönsson 2014; Lush, Walt and Ogden 2003; Morris, Cogill, and Uauy 2008; Schmitz 2016; Shiffman and Smith 2007). However, these dynamics are not fixed. Increasing agreement surrounding policy solutions helped the maternal health network (which seeks to reduce maternal mortality globally) find greater cohesion during the Millennium Development Goals era, facilitating the rise of the issue on global health and international development policy agendas in recent years (Smith and Rodriguez 2016). And although epistemic in nature, the network of actors championing integrated community case management (iCCM) of childhood illness also came to form a stronger coalition during the 2000s, facilitating that issue’s rise on the global health policy agenda (Dalglish et al. 2015; see also Haas 1992 on ­epistemic communities). A study of food and nutrition security policy communities suggests that the effects of coherence may be conditioned by commitment levels among members (Fox et al. 2015).

328   Stephanie L. Smith and Jeremy Shiffman There is some evidence to suggest that the legitimacy of actors conditions their power in the global health agenda setting process. For example, technical expertise was a legitimating factor that facilitated the participation of civil society organizations while tobacco industry actors were marginalized in WHO-led negotiations on the Framework Convention on Tobacco Control (FCTC), a binding international treaty on a health issue (Lencucha, Kothari, and Labonté 2011). The legitimacy of tobacco industry actors was in question because of economic conflicts of interest, as well as persistent industry efforts to undermine the public health–oriented tobacco control agenda (Collin, Lee, and Bissell 2002; Gneiting 2016; Gonzalez, Green, and Glantz 2012). Concerns about legitimacy have also limited the influence of alcohol producers and manufacturers of infant formula and highly processed foods (Moodie et al. 2013; Reich 1995).

Ideas Ideas are knowledge and beliefs about what ought to exist in the world. Ideas that motivate collective action are particularly powerful in the agenda setting process (Finnemore and Sikkink 1998; Sabatier and Jenkins-Smith 1993). Frames (lenses through which issues are understood) and norms (shared expectations for the ­behaviour of actors with a particular identity) are the central ideational variables in global health agenda setting scholarship (Finnemore and Sikkink 1998; Katzenstein 1996; Snow et al. 1986). Political actors define and portray problems in particular ways to assign blame and responsibility (Stone 1989). Effective causal stories unify concerned actors and assign responsibility to authorities, while muddled stories interfere with these crucial components of the agenda setting process. For example, decades of evidence establishing tobacco use as a major direct cause of disease and death helped to unify concerned actors, shift perceptions of the issue from an individual to a population health problem for which industry is culpable, and bolster the case for the FCTC (Gneiting 2016). In contrast, alcohol control has a more complicated causal story than tobacco control, contributing to its challenges in gaining traction on the global health policy agenda (Gneiting and Schmitz 2016). Complicated causal stories have inhibited agenda setting for other global health issues, including non-communicable diseases, surgery, mental health, oral health, health systems strengthening, and universal health coverage (Benzian et al. 2011; Brolan and Hill 2016; Geneau et al. 2010; Hafner and Shiffman 2013; Jönsson 2014; Shawar, Shiffman, and Spiegel 2015; Tomlinson and Lund 2012). Scholars have provided evidence that widely agreed upon solutions, and perceptions that problems are severe and tractable, facilitate agenda setting (Keck and Sikkink 1998; Snow et al. 1986; Stone 1989). Such shared ideas have helped to advance agenda setting for polio, malaria, tobacco control, tuberculosis, maternal health, newborn survival, sexually transmitted infections, and nutrition globally and nationally (Gneiting 2016; Lush, Walt, and Ogden 2003; Ogden, Walt, and Lush 2003; Pelletier et al. 2012; Quissell

Politics of Global Health Agenda Setting   329 and Walt 2016; Shiffman 2016a; Shiffman, Beer, and Wu 2002; Smith and Rodriguez 2016; Smith, Shiffman, and Kazembe 2014). A lack of credible indicators, or perceptions that a problem cannot be addressed cost-effectively or with appropriate technologies in resource-poor settings, have hindered efforts to raise the agenda status of certain issues, ranging from stillbirths to oral health, surgery, and the sexual and reproductive health of elderly populations (Aboderin 2014; Benzian et al. 2011; Frøen et al. 2016; Shawar, Shiffman, and Spiegel 2015). Drawing on such insights and evidence from a study of priority setting for the control of diarrhoeal diseases, Bump, Reich, and Johnson (2013) suggest that this issue could benefit from a shift to framing the problem as vaccine preventable and integral to a package of essential child health interventions. Recent work by Parkhurst (2017) and an account by Storeng and Béhague (2017) of the pressures to produce evidence of the severity and tractability of the global maternal ­mortality problem underscore contributions of the politics of evidence to the frames that proponents and opponents employ. Frames can shift over time, helping to raise an issue’s agenda status. For example, in the 1970s framing of an alternative to vertical and highly medicalized approaches to healthcare that had been the focus of international health promotion for decades, helped build international support for primary healthcare, which was immortalized in the Alma-Ata Declaration (Cueto 2004). The shift in framing from ‘female genital cutting’ to ‘female genital mutilation’ precipitated an increase in attention to the issue in the 1990s (Keck and Sikkink 1998). Likewise, the shift in framing neonatal mortality as an intractable problem to one that could be effectively addressed with low-cost communitybased interventions helped to change its trajectory in the 2000s (Shiffman 2016a). And though universal health coverage was initially held back by a perceived lack of evidence for efficacy in improving health outcomes (Brolan and Hill 2016), its framing as a solution to the problem of weak national health systems helped it advance on the global health agenda (Fox and Reich 2015). The portrayal of universal health coverage as a health and human rights issue also shaped attention to the issue in negotiations on the Sustainable Development Goals agenda (Forman, Ooms, and Brolan 2015). There is some evidence suggesting that a central set of dominant frames may be employed to facilitate agenda setting and shape policy responses. McInnes and colleagues (2012; McInnes and Lee 2012) investigate the use and influence of such frames—including evidence-based medicine, security, economics, development, and human rights—across several issues. Woodling, Williams, and Rushton (2012) show how security framing was used to draw attention to acquired immunodeficiency syndrome (AIDS) and then how AIDS was reframed as a development issue to maintain its prominence during the Millennium Development Goals era. Kamradt-Scott (2012) shows how evidence-based medicine and security frames complement each other in advancing pharmaceutical-based interventions for pandemic influenza. Williams (2012) shows how economic frames influence policies on access to medicines, with human rights–based pro-access framing having only limited impact on outcomes. Overall, the studies suggest that these frames are frequently and powerfully employed, may compete with or complement each other, and shape the collective response to issues (McInnes and Lee 2012).

330   Stephanie L. Smith and Jeremy Shiffman Finally, advocates have raised the agenda status of issues by aligning them with existing international norms (Price 1998; Katzenstein 1996; Keck and Sikkink 1998). Rushton (2012, S164) finds that, when opponents of travel restrictions on people living with the human immunodeficiency virus (HIV) or AIDS framed the issue in human rights terms, ‘backed-up by reference to international norms and to explicit commitments and obligations to avoid discrimination,’ the issue advanced more rapidly. Shiffman (2016a) suggests that newborn survival advanced on the global health policy agenda in part because concerned actors aligned the issue with the child survival norm advanced by Millennium Development Goal 4; neonatal mortality reduction was necessary to achieve the child survival goal. Smith and Rodriguez (2016) find that maternal survival benefitted from alignment with two powerful international norms, including a women’s rights norm through the 1990s and the poverty reduction norm represented by the Millennium Development Goals since 2001.

Interests Global health agenda setting scholars also seek to understand the ways in which interests shape actor behaviour and whose interests prevail in the process. Interests are preferences affected by the benefits or losses that accrue (or are expected to accrue) to an actor because of a set of conditions. Neorealist theory is premised on the notion that actors are driven by self-interest (Mearsheimer 1994–1995). Researchers ask such questions as how the economic and security interests of nations, and the profit motives of corporations, influence the agenda setting process. Research strongly suggests that material interests, including threats to national security and the economy, play significant roles in health agenda setting at the global and national levels (Feldbaum, Lee, and Michaud 2010; Labonté and Gagnon 2010; McInnes and Lee 2006; Ruckert et al. 2016; Rushton 2011; Watt, Gomez, and McKee 2014). An issue is more likely to emerge on the global health agenda if the interests of powerful actors align (Brolan and Hill 2016; Collin, Lee, and Bissell 2002; Reich 1987). Economic interests play central agenda setting roles for many global health issues. Reich (1987), for example, observed that when WHO moved to prioritize essential drugs in the late 1970s, it designed vague recommendations in consideration of the pharmaceutical industry’s economic interests, helping to maintain industry support for the action. Economic interests of the pharmaceutical industry and low-income countries shaped actor behaviour in the cases of praziquantel availability (Reich and Govindaraj 1998) and universal access to antiretroviral (ARV) drugs (‘t Hoen et al. 2011; Kapstein and Busby 2010). In the case of praziquantel, a Korean company worked with national governments prioritizing schistosomiasis treatment to produce and offer the drug at a lower cost than competitors. World Bank loans helped some highly burdened countries make the treatment widely available, though significant gaps in access remained through the 1990s. In the case of ARVs, pharmaceutical companies doubted a market

Politics of Global Health Agenda Setting   331 existed in low-income countries, and low-income countries could not afford the high prices of ARVs (Kapstein and Busby 2010). Concerned actors worked on supply and demand to convince pharmaceutical companies and national governments to be involved in making ARVs available to disadvantaged populations. Economic interests are behind regulatory opposition from several health-related industries, including tobacco, alcohol, infant formula, and food manufacturers (Moodie et al. 2013; Reich 1995), while a desire to expand markets and build brands is behind industry support for other issues, such as menstrual hygiene management (Sommer et al. 2015). Global public-private partnerships, including initiatives like the Global Alliance for Vaccines and Immunization (GAVI) and the Global Fund to Fight AIDS, Malaria and Tuberculosis (Global Fund), are built at the intersection of economic and public health interests, helping to draw attention and resources to focal issues, though not without raising questions about the influence of private interests and the distribution of resources (Buse and Walt 2000a, 2000b; Reich 2002). In terms of security interests, concerns about the risk of bioterrorism (such as the deliberate use of anthrax and smallpox) and the potential spread of lethal communicable diseases (such as HIV/ AIDS, tuberculosis, H1N1, and Ebola) have fuelled growing attention to several global health issues (McInnes and Lee 2006; Ruckert et al. 2016; Rushton 2011). For example, security interests helped to bring tuberculosis back onto the global health policy agenda during the 1980s, as the burden of the disease increased and its multidrug-resistant variant and HIV emerged in high-income countries (Ogden, Walt, and Lush 2003; Raviglione 2003). Security concerns have prompted several states to institute travel restrictions on people living with HIV/AIDS, as well as people living in countries affected by the Ebola virus, H1N1 influenza virus, and SARS (severe acute respiratory syndrome), although evidence is mixed on the public health benefits of such actions (Bajardi et al. 2011; Epstein et al. 2007; McInnes 2016; Rushton 2012). Concerns about the potential impacts of HIV/AIDS and the Ebola virus prompted the UN Security Council to allocate high-level attention to global health for the first and second times in its history, in 2000 (Resolution 1308 on HIV/AIDS and international peacekeeping operations) and 2014 (Resolution 2177 urging an end to isolation of ­Ebola-affected states). Some research suggests that national security- and economic interest–based arguments are more influential drivers of the global health agenda than health equity and human rights norms (Feldbaum, Lee, and Michaud 2010; Labonté and Gagnon 2010), but studies across a range of issues have found both types of factors play significant roles. For example, in the case of universal access to ARV drugs, Kapstein and Busby (2010) found normative commitments to be an essential companion to changes in material incentive structures. Rushton (2012) found that several countries moved to lift travel restrictions on people living with HIV/AIDS because they were influenced both by arguments that such restrictions did not serve national interests and by international and domestic norms that eschewed discrimination. Lush and colleagues (2003) found syndromic management of sexually transmitted infections gained traction in the 1980s and 1990s because of the problem’s association with HIV, evidence of effectiveness in addressing

332   Stephanie L. Smith and Jeremy Shiffman both issues and growing reproductive health norms. Lencucha and colleagues (2011) found civil society organizations shaped the contours of the FCTC by leveraging ­economic development and moral arguments. Sommer and colleagues (2015) found increased attention to, and action on, menstrual hygiene management was rooted in principled concerns for gender disparities in education, evidence of health benefits when girls complete their education, and corporate interests in expanding markets.

Institutions Institutions are ‘collections of structures, rules, and standard operating procedures’ that are relatively enduring and shape actor expectations, preferences, and behaviour (March and Olsen 2006, 4). Aid structures, accountability regimes, and ethical standards play such roles in the global health arena. Global health agenda setting scholars are principally interested in explaining why issues rise and fall on policy agendas; therefore, institutional variables tend to come to the fore of analyses when they help to explain change and fade into the background when they do not. Cases that highlight the influence of international human rights treaties, rules governing participation in UN processes, and trade and patent laws provide insights into the roles of institutions in shaping the global health agenda. Rules governing participation in processes related to the WHO-sponsored FCTC— with some formed to include and others to exclude particular actors—offer examples of ways in which institutions shape the agenda. First, as work to advance the FCTC began in the late 1990s, many civil society organizations were effectively blocked from participating by the multi-year process for attaining official relations status with WHO. Seeking broader political and technical support for the treaty, member states approved an accelerated and expanded process for expert NGOs to attain official relations and consultative status, bringing significant new resources to bear on the FCTC process (Collin, Lee, and Bissell 2002). The change in rules governing consultative relations facilitated expansion and diversification of the network of actors concerned with the harmful effects of tobacco use. The expanded network, among other contributions, educated delegates on technical aspects of the proposal, lobbied governments, waged media campaigns, exposed deceitful tobacco industry practices, and countered obstruction from some governments, elevating the FCTC on global and national policy agendas (Collin, Lee, and Bissell 2002; Lencucha, Kothari, and Labonté 2011). By way of contrast, industry actors were formally excluded from the FCTC negotiation process, limiting their influence to representation through third parties, such as ‘friendly governments’ (Gonzalez, Green, and Glantz 2012, 5). In addition, Article 5.3 of the FCTC and related implementation guidelines support parties in insulating the policy process from tobacco industry interference in accordance with national law, though selective adoption of recommendations provides continuing opportunities for industry influence in many countries (Fooks et al. 2017).

Politics of Global Health Agenda Setting   333 The case of universal access to ARVs demonstrates the influence of trade and patent laws as institutional forces in the global health agenda setting process. The high price of ARVs at the turn of the twenty-first century was a key factor preventing countries and donors from seeing universal access as feasible, initially limiting support for the solution (‘t Hoen et al. 2011; Kapstein and Busby 2010). The Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) had severely restricted the production of low-cost generics (‘t Hoen et al. 2011). Civil society outrage over limited access to medicines by the poor generated political pressure to address the problem. The World Trade Organization (WTO) addressed this pressure in 2001 with the adoption of the Doha Declaration on TRIPS and Public Health, which supported the rights of member states to protect public health and expand access to medicines for all (‘t Hoen et al. 2011; World Trade Organization 2001). The Doha Declaration and subsequent amendments opened the door to expanded production and distribution of affordable generic ARVs, galvanized WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS) to significantly increase the number of people using ARVs, and helped the Global Fund and the newly launched PEPFAR (the US President’s Emergency Plan for AIDS Relief) to leverage further funds. These developments helped propel HIV/AIDS to the top of the global health agenda in the early 2000s. Another example is how international human rights treaties have facilitated agenda setting for maternal and reproductive health. One approach to advancing attention to maternal mortality reduction has been to appeal to state obligations to secure the right to health for women, which is guaranteed under specific international treaties (Yamin and Maine 1999). Such rights were enforced under a 2011 decision by the Committee on the Elimination of Discrimination against Women (the body charged with overseeing implementation of states’ obligations under the Convention on the Elimination of All Forms of Discrimination against Women [CEDAW]). The committee established ‘that States have a human rights obligation to guarantee women of all racial and economic backgrounds timely and non-discriminatory access to appropriate maternal health services’ (de Mesquita and Kismödi 2012, 79). Further, a human rights–based approach provides a legal framework that has been used to justify maternal health programs and guidelines advanced by UN agencies, as well as underpinning commitments made at major international forums, such as the 1994 International Conference on Population and Development (Filippi et al. 2006; Gruskin et al. 2008). These structures, rules, and commitments in turn influenced the contents of the UN Millennium and Sustainable Development Goals, normative platforms that are themselves significant indicators of global health and international development priorities.

Discussion Existing research provides wide-ranging insights into the various factors shaping global health agenda setting. The capabilities of actors matter, including those of

334   Stephanie L. Smith and Jeremy Shiffman ­olicy entrepreneurs, high-level champions, and networks. So do their ideas, p ­particularly about problem definition, solutions, and causal stories. Interests are critical, particularly security and economic concerns of powerful countries ­ and  industries. And institutions—such as international law and trade regimes— structure the process. While many factors are influential, research indicates that several are present in most instances of the rise to prominence of a global health issue. These include (1) a perception that the problem is severe, (2) a clear causal story concerning why the problem exists, (3) a perception that the problem is soluble, and (4) an expectation that public authorities have a responsibility to address the problem. Global governing bodies and national governments rarely allocate significant attention and resources to issues that lack one or more of these facilitating factors. Other factors appear to matter more under some conditions than others. For problems that affect groups such as newborn babies and adolescent girls, who have little political power or pose no obvious security or economic risks to dominant countries, strong champions or networks are usually instrumental. In addition, certain kinds of ideas, such as frames aligned with international human rights norms, may take on significance when such marginalized groups are involved. Such actors and ideas may matter less when dominant countries or groups feel under threat, as political and economic elites can be expected to exert power to ensure that policymakers protect their interests. These dynamics suggest that there may be multiple paths to prominent global health agenda status, aligned with the different categories of the factors noted above. Issues may rise due primarily to ideational factors, as global champions make principle-based arguments that resources should be provided to address a problem. Maternal survival and some neglected tropical diseases fit this pattern. Issues may also gain prominence due primarily to interest-oriented factors, as powerful actors understand their economic or security concerns to be under threat or perceive a potential gain from a condition receiving attention. Ebola and SARS fit this pattern. A combination of ideational and interest-based influences may shape the ascendance of other issues that threaten both marginalized and powerful groups. HIV/AIDS is an example: grassroots advocacy, policymaker fears in industrialized states, and ­pharmaceutical company desire for profit from potential drug sales all shaped its rise to prominence as a global health issue. Research also indicates that actors and their ideas and interests, on the one hand, and institutions, on the other, interact to shape global health agenda setting. Institutions such as human rights laws and trade regimes structure the agenda setting process, favoring some issues over others. However, these are not determinative; operating within institutional constraints, actors are instrumental in shaping whether an issue becomes prominent. Moreover, actors are involved in reshaping these very institutions. These observations connect to long-standing social scientific debates about the relative roles of agency and structure in shaping social processes. Global health agenda setting research supports the contentions of some scholars that rather than being separate,

Politics of Global Health Agenda Setting   335 agentic and structural forces are mutually constitutive, and that both influence social processes, including agenda setting. This chapter synthesized research on global health agenda setting. A growing number of studies also focus on health agenda setting at the national and subnational levels, many with attention to the influence of global dynamics. Readers concerned with health agenda setting processes across global and national spheres will want to be aware of both bodies of scholarship. Among the theoretically grounded recent contributions in this vein are analyses of the following: • Differing beliefs among advocacy coalitions in Iran’s tobacco control arena, a study that draws on the ‘advocacy coalition framework’ (Sabatier and Jenkins-Smith 1993), a prominent model of the policy process (Khayatzadeh-Mahani et al. 2017). The analysis draws attention to influences of differing beliefs among pro- and antishisha smoking ban coalitions in Kerman Province, weak support outside the health policy subsystem, and autocratic governance arrangements. • The role of national networks in three cases of health policy change in Burkina Faso, a study that, like this chapter, considers the integrative roles of ideas, interests, and institutions (Shearer et al. 2016). Among other insights, policy reforms are traced to effects of new donor rules in introducing different actors and ideas to child health and malaria networks. • The influence of actors, ideas, and subnational political contexts on agenda setting for maternal survival in India (Smith 2014). The analysis draws attention to roles of policy entrepreneurs, framing, and differing sociopolitical legacies in two states. Critically, Tamil Nadu’s non-Brahmin social movement was facilitative, while Karnataka’s developmental disparities combined with decentralized governance structures to hinder progress. • How gender-based violence emerged as a health issue in Nepal, integrating framing theory into Kingdon’s (1995) multiple streams model (Colombini et al. 2016). A domestic violence bill was adopted only once policy elites framed the issue in human rights terms, facilitating alignment of the problem, policy, and politics streams. • The rise of a national health insurance scheme (Rashtriya Swasthya Bima Yojana) on the policy agenda in India, also drawing on Kingdon’s streams model (Shroff, Roberts, and Reich 2015). The analysis shows how a resourced group of domestic policy entrepreneurs worked with international agencies to advance the reform effort and secure its adoption. • How vertical birth practices among indigenous women made it onto the policy agenda in Ecuador, a study that draws on Kingdon and the ‘punctuated equilibrium’ theory of the policy process (see below) (Llamas and Mayhew 2016). The analysis draws attention to the influence of indigenous actors—rarely considered in agenda setting studies—and to the local socio-economic and political contexts that shape actor behaviour, as well as perceptions of problems and their solutions.

336   Stephanie L. Smith and Jeremy Shiffman

Considerations for Future Research on Global Health Agenda Setting Future global health agenda setting research should investigate several theoretically grounded hypotheses and research questions that hold promise for strengthening and adding insights to existing scholarship. Critical questions corresponding to the categories of factors discussed in this chapter include the following: • How does agenda setting differ for issues affecting marginalized versus elite groups? Specifically, how does the social construction of affected groups (Schneider and Ingram 1993) influence the process and its outcomes? Does the power of a frame (human rights, security, public health, economics, etc.) vary by population affected? • How does the composition of networks (which may change over time) affect global health agenda setting? How do diversity, representation from key stakeholder groups, and commitment factor in? Are close-knit coalitions of like-minded actors more effective at some tasks (e.g., establishing the severity of problems and their tractability) and networks that form broad political alliances more effective at others (e.g., attracting support from high-level leaders)? • Do the agenda setting process and its outcomes vary when rules for actor participation differ? How do civil society and industry participation matter? How do legitimacy perceptions factor into participation rules across venues? • How does resource scarcity—increasingly a concern given the recent wave of national populist politics in high-income settings—shape the dynamics of competition among global health issues? Will such scarcity adversely affect newly prominent issues on the global health agenda—such as universal health coverage—if resources become concentrated on specific initiatives targeting HIV/ AIDS, polio, Ebola, and other prominent diseases? Or have these newly prominent issues carved out a secure place on the agendas of global health institutions? Other global health agenda setting questions that extend the scope of the analytical framework used in this chapter include the following: • How are advances in communications technologies, including social media, shaping the global health agenda setting process? Are they democratizing it? If so, to what extent, and with what effects? • How does the agenda setting process vary when effective intervention means engagement beyond the health sector—across multiple policy arenas? Under what conditions and to what extent do public health–oriented networks engage other

Politics of Global Health Agenda Setting   337 policy arenas, such as sanitation, energy, environment, and economic development? What strategies do networks employ, and how effective are they? • How do global- and national-level agenda setting processes affect each other? To what extent do network factors, such as the quality of linkages between global- and national-level actors and the extent to which framing strategies are tailored to context, explain variation at the national level? Future global health agenda setting research should employ multiple methodological approaches to investigate these and other questions. Most global health agenda setting studies have been of single cases (Walt et al. 2008; Gilson and Raphaely 2008). These studies suggest hypotheses but invite questions about the strength of causal inference and generalizability. How applicable, for example, are findings from a case study of agenda setting on tuberculosis to diabetes, road traffic injuries, or universal health coverage? How do the most influential factors vary by characteristics of the issue? Are agenda setting dynamics different depending on type of venue or arena (e.g., WHA, UNSC, Gates Foundation, national government, media outlets)? If so, in what ways, and which venue attributes matter? Under what circumstances do interests dominate? Under what circumstances do ideas dominate? Which institutions are most critical? All these questions are more likely to be answered if scholars employ a range of study designs and in particular draw more comprehensively on syntheses and comparative and large-N approaches to complement the strong case study work already in existence. Some medium-N comparative studies, including those on framing (McInnes et al. 2012) and networks (Shiffman 2016b), have begun to address the comparative research challenge, providing insights into global health agenda setting processes. Critical systematic reviews assessing the generalizability of a policy framework for analyzing health priority setting (Walt and Gilson 2014) and seeking to explain dynamics of global health diplomacy (Ruckert et al. 2016) are among other substantive contributions in this vein (see also Gilson 2014; Berlan et al. 2014; Erasmus et al. 2014; Gilson, Schneider, and Orgill 2014; Erasmus 2014). A pertinent tradition of large-N research exists in the field of comparative public policy (see especially The Comparative Agendas Project at http://www. comparativeagendas.net/). Future global health agenda setting research would also benefit from more systematically drawing on existing models of the policy process (Sabatier 2007; Sabatier and Weible 2014), as many of the works cited in this chapter have done (Walt et al. 2008). Among these is Kingdon’s (1995) multiple-streams model, the most widely used model in global and national health agenda setting scholarship. Kingdon argues that the public policy process has a random character, with problems, policies, and politics flowing along in independent streams. The problems stream contains the broad problems and conditions facing societies, some of which become identified as issues that require public attention. The policy stream refers to the set of policy alternatives that researchers and others propose to address problems. This stream contains ideas and technical proposals on how problems may be solved. Political transitions, national mood, and social

338   Stephanie L. Smith and Jeremy Shiffman pressure are among the constituent elements of the politics stream. At particular junctures the streams merge, and at their confluence windows of opportunity emerge and ­governments decide to act. Developed by Sabatier and Jenkins-Smith (1993), the Advocacy Coalition Framework (ACF) has also been widely employed to study the agenda setting process (Sabatier and Weible 2007; Jenkins-Smith et al. 2014). Part and parcel of the growing literature on roles of networks in the policy process, the ACF posits that coalitions of specialized elite actors advocate for issues within substantively and geographically bound policy ­subsystems. Advocacy coalitions are motivated, and their strategies are guided, by shared beliefs that tend to be highly stable but can change as a result of policy-oriented learning or external perturbations or shocks. Divergent beliefs and preferences (discussed in terms of ideas in this chapter) form the basis for conflict among coalitions. According to the ACF, deep core beliefs and policy core beliefs are resistant to change, but secondary beliefs concerning details of causal stories in specific localities and programmatic rules and procedures, for example, are narrower in scope and more amenable to change. Contextualizing the framework’s application, policy ­subsystems and the actors that operate within them are understood to be affected by  factors exogenous to the subsystem, including relatively stable parameters (e.g., basic constitutional, sociocultural, and resource structures) and external events (e.g., changes in socio-economic conditions, public opinion, governing coalitions, and other subsystems). Major policy change is hypothesized to be a product of ­policy-oriented learning, external shocks, internal shocks, or ‘a hurting stalemate’ (Sabatier and Weible 2007, 208). Another influential agenda setting model is that developed by Baumgartner and Jones (1993), punctuated equilibria, which postulates that the policymaking process is characterized by periods of stability with minimal or incremental policy change, disrupted by bursts of rapid transformation. Central to their policy theory are the concepts of the policy image and the policy venue. The policy image is the way in which a given problem and set of solutions is conceptualized. One image may predominate over a long period of time, but it may be challenged at particular moments as new understandings of the problem and alternatives come to the fore. Policy venues are locations at which authoritative decisions are made and that actors target. Some actors may hold monopoly power but will eventually face competition as new actors with alternative policy images gain prominence and engage alternative venues. When a particular policy venue and image hold sway over an extended period of time, the policy process will be stable and incremental. When new actors targeting new venues and new images emerge, rapid bursts of change are possible. Thus, the policy process is marked both by stability and change, rather than by one or the other alone. In sum, scholars have contributed much to the state of knowledge concerning the different factors shaping global health agenda setting. They can further advance understanding through the use of analytical frameworks such as the one presented in this chapter and the employment of rigorous research methods, comparative designs, and existing policy process models.

Politics of Global Health Agenda Setting   339

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chapter 18

The Politics of I n terg ov er nm en ta l Orga n iz ations i n Gl oba l H e a lth Tine Hanrieder

Intergovernmental organizations (IGOs) form part of a complex landscape of public and private national, regional, and global actors that contribute to global health gov­ern­ance (Youde 2012). What distinguishes IGOs from other global actors such as non-governmental organizations (NGOs) is that their authority is directly derived from state sovereignty, because the existence of IGOs is based on a multilateral governmental act.1 This endows them with a special legal status and formal legitimacy on the one hand and creates a peculiar dialectic of dependence and authority vis-à-vis their member states on the other. To assess the role of IGOs in global politics, a huge body of literature in the field of international relations (IR) addresses questions such as how IGOs exert authority (Barnett and Finnemore 2004), how they do or don’t escape state control (Hawkins et al. 2006), how they develop over time (Jupille, Mattli, and Snidal 2013), how they interact with other IGOs or NGOs (Abbott et al. 2015), and how their authority is contested in an emerging global public sphere (Zürn, Binder, and Ecker-Ehrhardt 2012). Most of these discussions revolve in some way or another around the problem of how autonomously IGOs can act and interact with their global environment. These questions are increasingly tackled by students of global health politics as well. While for a long time the ‘usual suspects’ (Haftel and Thompson 2006, 254) of IGO research were the big economic and security organizations, and studies of global health IGOs were relatively rare (but see Siddiqi 1995; Lee 1998). Health-related IGOs have moved center stage since the early 2000s. This new attention involves research on both organizations whose primary mandate is the promotion of health (such as the World Health Organization [WHO]) and organizations whose policies create externalities for global health (such as the World Trade Organization [WTO] through its intellectual

348   Tine Hanrieder property regulations). Thus, just as public health scholars began to draw attention to the global institutional forces that shape health outcomes worldwide (e.g., Lee 2003), IGO researchers have discovered the importance of IGOs in fields such as health security (Zacher and Keefe 2008) and development (Staples 2006). This chapter aims to show that the emerging research on health-related IGOs not only sheds light on the global institutional dynamics that affect health policies and services, but can also make new contributions to IGO research in general. For example, research on health-related IGOs has drawn attention to the nexus between global crises and IGO authority, highlighted mechanisms of coordination and divisions of labor between seemingly competing IGOs, and shown how historical constraints in IGOs bias the outcomes of current reforms. The chapter discusses the cross-fertilization between global health and IGO research by drawing on empirical examples from a variety of health-related IGOs. It is divided into two main sections. The first focuses on debates about IGO power, especially vis-à-vis states, and the second on debates about the sources of and constraints on IGO change.

Power of Intergovernmental Organizations in Global Health Multilateral cooperation in health dates back to the international sanitary conferences that took place between 1851 and 1938, at which state delegates developed a body of international sanitary regulations aiming to curb the transboundary spread of contagious diseases with minimum interference with travel and trade. WHO, created in 1948 as the United Nations’ (UN) central agency for international health work, became responsible for the application and updating of these regulations, which were renamed the International Health Regulations (IHRs) in 1969 (Fidler 2005; Lee 2009). WHO also inherited surveillance, standard setting, and policy development activities from several pre-existing international health organizations, most importantly the League of Nations Health Organization (1921–1946) and the Office Internationale d’Hygiène Publique (1907–1946). It thus became the central standard setter, policy adviser, and service coordinator in international health work in the post–World War II era (Lee 2009). Thus from the outset the work of WHO has illustrated the three ‘roles’ that IR researchers have distinguished for IGOs (Rittberger, Zangl, and Kruck 2012, 6). As an arena of state interaction, WHO serves as an institution in which states convene, exchange views, and reach agreements on its policies and its (mostly non-binding) standards for global public health (Burci and Vignes 2004). This role is mainly assumed through the annual World Health Assembly (WHA), at which delegates from WHO’s 194 member states jointly set global health standards and agree on the budget and priorities of WHO secretariat’s work. As an instrument of state diplomacy, WHO’s outputs help states coordinate their measures against infectious diseases (even though

Politics of Intergovernmental Organizations   349 this function was closely circumscribed before the 2005 revision of the IHRs; see “Sources of IGO Autonomy in Global Health”) and exchange information on the basis of common standards. Finally, in executing the tasks that states delegate to WHO, and through its secretariat of approximately seven thousand staff members at the Geneva headquarters, the six regional offices, and some 150 country offices, the WHO assumes its role as an actor in global health politics. In this role, WHO bureaucracy prepares the decisions of the WHA, engages in global disease surveillance and outbreak control, develops guidelines, makes policy suggestions, and gathers and updates public health statistics. It also advises national ministries of health, coordinates the health services and emergency responses of other health-related IGOs and NGOs, and to a very limited extent delivers health services by itself (Lee 2009, 18–21). The activities of other IGOs whose work targets or affects global health politics similarly oscillate among these roles, yet with different emphases. The World Bank, for example, which has long been a major player in the fight against individual diseases as well as the reform of entire health sectors in developing countries (see Youde 2012, 46–62), has a strong actor component. Its secretariat of about ten thousand staff members has considerable discretion in shaping the conditions of World Bank loans (Weaver 2008). As a state instrument, its work is tailored to the preferences of powerful states by design, because the votes of states on the bank’s executive board are proportionate to their monetary contributions-unlike other UN organizations such as WHO or the United Nations Children’s Fund (UNICEF), in which at least formally the one state, one vote principle ensures an equal say for all members of the WHA. Still, research on IGOs has also shown that their formal rules alone do not account for the actual power relationships between states and IGOs. For example, informal channels of influence (Stone 2011), organizational cultures (Barnett and Finnemore 2004), and the degree of (dis-)agreement between member states (Copelovitch 2010) affect both the extent of IGO autonomy from state control and the extent of IGO influence on state behavior. The following sections discuss these two aspects of IGO power in more depth.

Sources of IGO Autonomy in Global Health There are two main strands of IGO research that seek to account for the relative autonomy of IGOs vis-à-vis states: bureaucratic culture theory on the constructivist side and principal-agent theory on the rationalist side. The first approach, which has been prominently outlined by Barnett and Finnemore (2004), emphasizes the organizational properties of IGO secretariats as bureaucracies: their ‘bureaucratic culture’ consisting of specific rules, routines, and ideologies, which set IGOs apart from their environment and generate distinct behavioral tendencies. This cultural identity as ‘bureaucratic organizations’ also endows IGOs with a specific legitimacy and authority, because rule-based authority is highly valued in modern global society. IGOs are thus authorities, because they are perceived to be impartial and rational and to act as trustees of shared global values. They exert this authority through ideational means, for example by classifying

350   Tine Hanrieder who is entitled to refugee status and thus worthy of international protection, or by fixing the meaning of values such as development, growth, or human rights. Importantly, this bureaucratic authority also generates dysfunctional tendencies and thus IGO pathologies. In particular, Barnett and Finnemore highlight IGOs’ limited ability to learn from changes in the world for which their ingrained routines are not appropriate. IGOs are therefore bad at learning from failure. Their tendency to react to any problem with even more ‘bureaucratization’ means that IGOs devise new and even more expansive policies and thus expand their influence over time. For example, the International Monetary Fund (IMF) has repeatedly interpreted the failure of a macroeconomic stabilization program as an indication that the program had omitted parts of the economy, and that therefore more expansive IMF interventions and conditionalities (Barnett and Finnemore 2004, 71) were needed. Barnett and Finnemore centered their analysis on the IMF, the UNHCR, and the UN Department of Peacekeeping Operations (Barnett and Finnemore 2004). Interestingly, however, an earlier study of a health-related IGO, namely Jared Siddiqi’s monograph about WHO’s structural evolution and the failure of its malaria eradication program of the 1950s and 1960s, anticipated many of the claims made by Barnett and Finnemore (Siddiqi 1995). Siddiqi’s detailed account of one of the largest single disease projects in WHO’s history and its ultimate failure is an ideal-typical narrative of bureaucratic pathology. The author argues that for years the program discarded evidence that malaria eradication was failing and ignored realities on the ground such as lacking infrastructure or insufficient political commitment. The outcome was a half-finished eradication attempt resulting in growing resistance to DDT2 in many mosquito vectors and even backlash in many areas where malaria returned with a more fatal impact than before the eradication attempt (Siddiqi 1995, 123–191). In a recent study Chorev suggests that WHO’s internal bureaucratic features crucially shape its policies. She argues that the organization’s handling of policy conflicts between low-income countries and high-income countries is decisively mediated by the preferences and strategies of the secretariat (Chorev 2012). However, Chorev combines her emphasis on the values held inside the secretariat with an analysis of the kinds of pressures exerted on the secretariat by states. Ultimately, she suggests, it is the relative compatibility between bureaucratic values and external demands that defines how IGOs formulate their policies, or in other words, bureaucratic authority is exerted within the limits set by member states. The nature and institutional design of these limits is at the center of the second main approach to IGO autonomy and part of the rational institutionalist approach to global governance, namely principal-agent (PA) theory. It analyzes the contractual arrangements through which states delegate competencies to IGOs and the instruments through which states monitor and control the behavior of IGOs (Hawkins et al. 2006). From this perspective, the delegation of authority to IGOs, including discretion in the handling of their tasks, is rationally chosen by states that seek to save time and create synergies by working through IGOs. However, states also use a variety of monitoring and sanctioning techniques to make sure that IGOs do not act against

Politics of Intergovernmental Organizations   351 their interests; that is, they seek to avert ‘slack’ where IGOs overreach their delegated mandate. States seek to prevent slack, for example, by installing oversight bodies, by relying on the information of external agents such as NGOs or other IGOs, or by changing the contractual incentives and concomitant sanctions that direct IGO ­secretariats (Hawkins et al. 2006). Research on health-related IGOs, again especially on WHO, has extensively drawn on but also challenged the PA approach in two main respects: it has tested the limits of the meaning and dynamics of IGO discretion, especially in times of crises, and it has questioned the analytical utility of conceptualizing IGOs as coherent ‘agents’ in the first place. Regarding the first line of debate, the paradigmatic example is WHO’s growing discretion in the governance of global health crises. Ever since WHO’s robust reaction to the 2003 SARS crisis, scholars have debated whether WHO’s emergency powers are a normal case of delegation and discretion or an instance of ‘slack’ (Cortell and Peterson 2006), a problem that has returned with every new emergency, such as ‘swine flu’ in 2009 or the West African Ebola outbreak in 2014. Severe acute respiratory syndrome (SARS), a previously unknown form of pneumonia, first emerged in China in November 2002 and spread to thirty-two states within several months. In a climate of global fear of contagion, but faced with states like China that were reluctant to disclose information on the outbreak in their territories, the WHO secretariat became proactive in early 2003 and issued travel alerts against Hong Kong, Toronto, Taiwan, and parts of China. For Cortell and Peterson, this decision by DirectorGeneral Gro Harlem Brundtland was a ‘radical step’ that was not foreseen by the authority member states had delegated to WHO under the IHRs (Cortell and Peterson 2006, 255; drawing on Fidler 2004). Until then the IHRs had only allowed WHO to become active upon state demand and to draw on information made available by states-a rule and practice that was sidestepped during the 2003 SARS crisis. However, the WHO/SARS example also showed that IGO activities in times of crisis are difficult cases for PA theory, because member states may be slow to articulate their interests and create unusually permissive conditions for autonomous IGO decisions. Even though WHO’s reaction to SARS exceeded its legal mandate as specified in the IHRs (and even here, one can find arguments to the contrary; see Kamradt-Scott 2015), it is also clear that states readily bought into this new assumption of authority by the secretariat (Zacher and Keefe 2008, 66). In fact, at least some of the competencies that WHO arrogated in 2003 had been debated in preceding IHR reform talks, and most of these competencies-such as WHO’s ability to draw on nonstate sources of information and issue recommendations that cannot be vetoed by states-were later sanctioned by WHO’s member states through the 2005 reform of the IHRs (Hanrieder and Kreuder-Sonnen 2014; Kamradt-Scott 2015). Hence the SARS case and the subsequent IHR reform illustrate the growing authority of WHO in health security matters-a growth in authority that was critically debated but not reversed after the ill-managed response to the West African Ebola outbreak in 2014. While WHO was heavily blamed for its slow response to the Ebola outbreak, it was also acknowledged that WHO’s tight and closely earmarked budget and the traditional

352   Tine Hanrieder ‘normative’ focus of its mandate as a consultant and coordinator had hampered its ability to act in the first place (McInnes 2015). Indeed, post-Ebola reform efforts such as endowing WHO with emergency funds and a standby emergency workforce (see “Inter-organizational Dynamics of Change”) make it clear that states keep supporting a special discretionary role for WHO in the face of unforeseen events. This institutional dynamic in the domain of global health security also sheds a new light on the broader question of IGO agency in times of crisis. Global health scholars have accounted for the empowering effect of crises on IGOs by combining insights from PA theory and critical security studies, showing how the ‘securitization’ of health threats creates demand for IGO authority (Hanrieder and Kreuder-Sonnen 2014; Kamradt-Scott 2015). These insights open up new avenues for research into the ways in which phases or instances of exceptionalism affect IGO authority in various issue areas of global governance (Kreuder-Sonnen 2016). A second contribution to PA theory that is also based on research on WHO points to a thus far neglected source of agency slack: the problem that in many cases WHO does not behave as one, but as many, actors. Studies of WHO’s performance in the domains of primary healthcare and HIV/AIDS suggest that the organization often fails to be responsive to its ‘principals’ (member states in PA terminology), because different parts of the organization are working at cross-purposes. One reason is the exceptionally strong role of WHO’s six regional offices, which were granted a special status in the WHO Constitution and have consolidated their position ever since (Hanrieder 2015a). The regional office’s poor coordination with WHO’s central secretariat has been criticized throughout the organization’s history, most recently during the 2014 Ebola ­epidemic, when the regional office of the African region barely collaborated with WHO’s secretariat or with external agencies such as the US Centers for Disease Control and Prevention (CDC) (Sack et al. 2014). This disconnect between WHO’s secretariat and its regional offices led Graham to conceptualize WHO as a ‘collective agent’, a phenomenon previously not foreseen by PA theory (Graham 2014). Hanrieder also stresses this regional dimension of ‘fragmentation’ of the WHO actor and adds a second dimension, which is the organization’s growing dependence on extra-budgetary donations. This leads to the emergence of separate, donor-sponsored programs with relative autonomy from the WHO director-general and thus exacerbates the problem of fragmented agency (Hanrieder 2015a). The incoherence of ‘the’ WHO agent leads to puzzling irregularities in WHO’s behavior that PA theory cannot account for. One is self-sabotage or ‘mission shrink,’ which happened to WHO’s Global Programme on AIDS in the late 1980s and early 1990s (Hanrieder 2014a). Another is a lack of ‘faithfulness’ to state demands because the fragmented agent is incapable of executing them (Graham 2014). These studies expose PA theory’s difficulty in handling situations in which IGOs cannot be conceptualized as coherent actors. Before discussing the question of how coherent patterns of change can be distilled from such complex constellations, the following subsection explores whether and how IGO autonomy from is matched by IGO influence on member states.

Politics of Intergovernmental Organizations   353

Sources of IGO Influence Besides the question of whether IGOs can act autonomously from state control, IGO research also asks to what extent IGO outputs actually influence the behavior of states. The factors highlighted by rational institutionalists-money and formal legal power are one important source of influence for many health-related IGOs. The World Bank and the IMF, for example, have had a profound impact on national health policies due to the conditionalities attached to their loans. The so-called structural adjustment programs (SAPs) of the World Bank and the IMF have imposed fiscal discipline and privatization programs on borrowing countries, measures whose adverse health effects have long provoked harsh criticism from the global health and development communities (Loewenson 1993; Benson 2001). Another factor highlighted by rationalists-the legalized nature of IGO outputs-accounts in particular for the power exerted by the WTO, mainly through its Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS). TRIPS requires WTO members to ensure intellectual property protection through measures such as copyright or patents. These regulations have had a profound impact on countries’ ability to produce affordable generic forms of vital medicines. Another source of IGOs’ influence is their ability to directly provide services on the ground. For example, UNICEF has long implemented maternal and child health ­programs and executed vaccination campaigns in developing countries. Notably, however, the central UN agency for international health, WHO, barely relies on hard international law or implementation capacities. Instead, it mostly steers state behavior through soft, non-binding standards (Burci and Vignes 2004). Even where WHO standards are formally binding, as in the case of the 2003 Framework Convention on Tobacco Control (FCTC) or the above-mentioned IHRs, WHO has few means to induce compliance by recalcitrant member states (Fidler 2005). For example, Worsnop (2016) shows that WHO member states often do not follow WHO recommendations about the maximum permissible travel and trade restrictions regarding states in which a contagious disease has broken out. They nevertheless shut down their borders with infected states, making it even more difficult to provide aid and fight the outbreak (Worsnop 2016). Yet as indicated above in the discussion of bureaucratic authority in IGOs, the factors emphasized by rationalists are not the only ones making IGOs powerful actors. The ideational authority of IGOs and thus their ability to define global issues is an important source of authority as well (Barnett and Finnemore 2004). In global health research, this line of reasoning is most prominent in works that draw on medical anthropology, a literature that is informed by a critical stance toward purely biomedical approaches to health and illness, and thus unpacks the assumptions and practices of meaning-making that underpin modern medical projects (Kleinman 1997). Taking up these anthropological insights, Sridhar (2008) has provided an in-depth ethnography of the World Bank’s politics of knowledge about hunger, a politics that conceptualized ‘malnutrition’ as a disease and made individual choices responsible for avoiding it. Her emphasis on

354   Tine Hanrieder the World Bank’s epistemology of hunger allows her to grasp the cognitive influence of IGOs on the very understanding of health and illness in global politics. This focus on practices of meaning-making is a promising avenue for further exploring the subtle influence of IGOs on the construction of health in world politics. Different measurements and conceptualizations of ‘health’ in global politics (Hanrieder 2016) and different connections made between the health and other policy fields (McInnes et al. 2014) are highly consequential for the priorities and substantive policies of global health projects. Hence, a combination of insights from the burgeoning anthropological literature on global health (Biehl and Petryna 2013) with IR insights on IGOs’ bureaucratic technologies of meaning-making promises to be a fruitful way to further explore the subtle, cognitive means through which IGOs shape global health politics.

Dynamics of Organizational Change The preceding section focused on the powers and properties of health-related IGOs. Yet to fully understand their role in a field as dynamic as global health governance, we also have to explore how IGOs change over time. Global health is a field marked by constant change. Processes like economic globalization and climate change transform the social and environmental determinants of health, and changing disease patterns require new responses. In addition, the organizational field of global health has grown ever more ‘crowded and competitive’ (Lee 2009, 99). Today, myriad IGOs engage in global health politics, adopting different approaches to health that are not always reconcilable. A host of nonstate actors such as NGOs, business actors, and philanthropists has entered the field, bringing in new and often competing ideas about health, social justice, and democracy, and publicly criticizing the work of established IGOs. Such contentious forces raise the question of how IGOs adapt to new challenges in their organizational environment, a question that is far from trivial given the sources of IGO autonomy discussed above. It is at the center of ongoing debates in IR dealing with dynamics of institutional change and with inter-institutional relations in world politics. These debates seek to understand how ‘path dependent,’ endogenous developments within the IGOs themselves interact with exogenous challenges to IGOs (Hanrieder and Zürn 2017). They shed light on patterns of change both within individual IGOs and between different IGOs.

Health IGOs between Forces of Stability and Pressures for Reform With IGO power comes responsibility-and contestation (Zürn, Binder, and EckerEhrhardt 2012). This is also true for the IGOs engaged in global health, which have often

Politics of Intergovernmental Organizations   355 been the object of criticism. The World Bank’s SAPs (see above) and its failures in the field of HIV/AIDS (Harman 2007), WHO’s delayed response to the West African Ebola outbreak in 2014 (Kamradt-Scott 2016), the TRIPS Agreement’s adverse effects on many people’s access to essential medicines (Löfgren and Williams 2013), and the importation of cholera into Haiti by UN peacekeeping forces in 2010 (Frerichs 2016) are only some of the instances in which IGO activities have provoked dissatisfaction and demands for change. The growing body of research dealing with patterns of IGO change also shows that IGOs rarely adapt in linear ways to their evolving environment (Rixen, Viola, and Zürn 2016). In fact, the very same factors that make IGOs autonomous in the first place (see above “Sources of IGO Autonomy in Global Health”) can also make them slow in responding to exogenous pressures; ingrained rules, institutional veto players, and procedural constraints often make IGOs inflexible and defy swift adaptation. Rather, IGO change is usually path dependent: channeled by pre-existing institutional structures and norms that bias how impulses for change are absorbed, or even generated, inside IGOs. Broadly, two types of impulses can be distinguished whose impacts on IGO change have been scrutinized in the literature: material pressure by powerful states (or donors) that seek to project their capacities onto the workings of IGOs and normative pressure by societal actors that seek to hold IGOs accountable to shared standards of good global governance. Regarding the first, IGO scholars have emphasized that actors such as donor states often cannot directly project their power within the structures of IGOs, because their voting rights and seats on executive boards only partially reflect their material power (Stone 2011). This makes powerful states resort to gradual and informal modes of change that allow them to circumvent the core structures and policies of IGOs (Stone 2011). These diversion strategies can generate distinct patterns of institutional development, which are shaped by the types of material and institutional power held by reform coalitions and thus also by the question of whether they face veto players inside an IGO (Hanrieder 2014a). In this vein, Hanrieder argues in her reform history of WHO that its regionalized structure has created a specific path-dependent dynamic, namely self-reinforcing fragmentation (Hanrieder 2015a). She claims that the initial decentralized design of WHO, giving factual veto power to the directors of the six regional offices, biased the outcomes of several major reform attempts toward further fragmentation. It forced organizational reformers to either compromise with the regional offices and thereby further strengthen them or circumvent the regions through the creation of new, additional organizational layers that were partially autonomous from the organization’s centralized management. In aggregate, therefore, reformers facing path-dependent constraints have produced a dynamic of ongoing fragmentation, which none of the involved actors can escape from unilaterally (Hanrieder 2015a). To escape such a constellation, dissatisfied actors would have to choose ‘exit’ and turn to or create new organizations, that is, seek change outside the IGO (see below “Inter-organizational Dynamics of Change”).

356   Tine Hanrieder The second source of change, normative pressure through public campaigns, naming and shaming, or persuasion strategies, has also long been an important driver of new developments in health-related IGOs. Civil society actors, especially when organized in transnational advocacy coalitions (Keck and Sikkink 1998), have repeatedly targeted health-related IGOs and also won some important victories. For example, population control policies promoted by the Rockefeller Foundation and IGOs such as the UN Population Fund have changed considerably in response to public pressure. While the 1960s and 1970s were marked by extremely intrusive measures—for example in India with practices such as forced sterilization and arrests of people who opposed population control—public protests against these practices did lead to change. The International Conference on Population and Development, held in Cairo in 1994, formulated ­so-called reproductive rights, such as access to family planning and education, to ensure that population policies do not infringe on human rights and especially women’s health (Connelly 2008). Similarly, in the 1970s transnational activists successfully pushed for a WHO/UNICEF code regulating the marketing of breast milk substitutes (Sikkink 1986). Nowadays, ever more civil society groups, such as the People’s Health Movement, are making WHO politics more transparent, and NGOs such as Health Action International challenge contentious outputs such as the intellectual property regime. Powerful movements, especially the campaigns of AIDS advocacy groups, have indeed helped to transform global pharmaceutical markets to ensure broader access to life-saving antiretroviral medicines (Kapstein and Busby 2013). Likewise, aspects of the WTO’s TRIPS Agreement have been refined to allow for public health safeguards, also due to pressure from civil society groups (Sell and Prakash 2004). However, just like responses to material pressure, IGO responses to normative campaigns are far from linear. Not all normative campaigns find resonance in IGOs. For example, the ‘Independent WHO’ campaign, asking for the WHO to take a stronger stance toward the International Atomic Energy Agency (IAEA) when it comes to identifying and combating hazards of nuclear energy, is hardly heard, in spite of recurring nuclear catastrophes.3 In addition, IGO responses to normative demands are also path dependent. They depend on IGO procedures for processing normative demands, at both legal-institutional and cognitive levels. Legal path dependence has played out, for example, in the case of the UN’s role in the 2010 cholera outbreak in Haiti. Pillinger and colleagues show how existing biases in international law shield UN organizations from demands for accountability (Pillinger, Hurd, and Barnett 2016). In spite of overwhelming evidence that cholera was brought to Haiti by UN peacekeepers, the UN has avoided any legal redress-or even open investigation of the epidemic (Frerichs 2016). Existing biases in international law, especially UN immunity, combined with Haiti’s vulnerability as an utterly dependent recipient of foreign aid, have produced a blatant disregard for the harm done to Haitians (Pillinger, Hurd, and Barnett 2016). Beyond formal immunity, IGOs have the means to divert demands for accountability. Not only in the UN Haiti case, but also in other IGOs such as WHO, ex post reviews of IGO failures are often performed by organs that are only partially autonomous from the IGO under scrutiny. A case in point is WHO’s investigation of its handling of the 2009

Politics of Intergovernmental Organizations   357 swine flu crisis, which was the first time that WHO activated its new capacity to declare a ‘public health emergency of international concern’ under the reformed IHRs (see the chapter by Kamradt-Scott in this volume). WHO’s secrecy regarding the names of its emergency committee members, and resulting concerns about potential conflicts of interest regarding the committee’s recommendations on vaccinations and antiviral therapies, led to critical external and internal investigations once the crisis was over (Hanrieder and Kreuder-Sonnen 2014). Still, WHO’s processing of these allegations was crucially mediated by its own IHR Review Panel, whose members were selected by the WHO Secretariat and which translated demands for change into recommendations for WHO action. This is a typical IGO procedure of handling criticism through ‘independent’ IGO review bodies appointed by the IGOs themselves. The Ebola Interim Assessment Panel chaired by Barbara Stocking was equally appointed by WHO and declared a body of ‘outside independent experts’;4 the UN ‘independent’ panel investigating the Haitian cholera outbreak of 2010 is another example of this evaluation practice. As Frerichs argues for the case of the cholera panel, its composition excluded those voices arguing that the UN peacekeeping mission had brought cholera to Haiti (2016, 156–169). To further explore the pathways through which IGOs filter critical stimuli and translate them into organizational action, scholars should look deeper into the cognitive and procedural tools through which IGOs ‘read’ their environments (Broome and Seabrooke 2012). Such an emphasis on information and communication dynamics is all the more important given that communication techniques are rapidly changing. On the one hand, the information and communication revolution has empowered IGOs vis-à-vis states when it comes to the surveillance of disease outbreaks. Such outbreaks are now reported through various professional and social networks that IGOs can draw on (Zacher and Keefe 2008). On the other hand, health-related IGOs have not been spared by the ongoing trend toward leakages revealing confidential documents about ongoing negotiation processes in IGOs (Mara 2009). Such public exposure may not only increase the pressure on IGO secretariats but also influence the actors who seek to shape formal constraints through informal and usually hidden channels of influence.

Inter-organizational Dynamics of Change Changing IGOs through formal and informal, hard and soft means is only one option for fostering change in global health governance. The other and widely used option is ‘exit’ (Hirschman 1970). Dissatisfied actors can withdraw their support from existing IGOs and use or even create new organizations that better suit their preferences (Jupille, Mattli, and Snidal 2013; Morse and Keohane 2014). Exit is an important means of change in global health politics, where myriad IGOs, NGOs, business actors, and philanthropists seek to promote global health (Inoue and Drori 2006). Governments, but also private donors like the Bill and Melinda Gates Foundation (see chapter by Youde in this volume), can draw on a broad array of health actors, including IGOs such as WHO or UNICEF, but also non-governmental actors such as Doctors without Borders/Médecins

358   Tine Hanrieder sans Frontières or one of the various public-private partnerships for health that were created around the turn of the millennium (Bull and Mcneill 2007, 66). IGOs are both rivals of and participants in many of these partnerships. For example, the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM, created in 2002) is governed by an executive board that also gives a say to representatives of IGOs, including the World Bank, WHO, and UNAIDS (although these IGO representatives only participate as non-voting members, unlike states, NGOs, and philanthropic board members5). Another major global health partnership, GAVI (Global Alliance for Vaccines and Immunization, created in 2000), has a similar board structure, although in this case IGOs have the same status as representatives of states, industry, NGOs, or independent individuals.6 This growing inter-IGO competition has raised questions about both the reasons for and the consequences of competition between IGOs. The reasons that states (and donors) choose to shift their support to new or different organizations, often while diminishing their support for those IGOs that they used to work with, are differently interpreted. One main functional reason identified in the IGO literature is states’ dissatisfaction with the performance of an IGO and thus the impression of states and donors that the institutional status quo is inefficient. This impression is often tied to new developments in the international environment (e.g., the emergence of new diseases), in response to which the old IGOs do not have the right means and procedures (Morse and Keohane 2014, 390). Still, not all dissatisfaction leads to immediate exit. Rather, it is stressed that states are reluctant to make such changes due to sunk investments in existing IGOs and the switching costs that accompany exit. Thus, dissatisfaction must reach a certain threshold for states to actually withdraw from an IGO they used to work with (Jupille, Mattli, and Snidal 2013). However, a purely functional account does not capture the entire problem of exit from IGOs. Perceptions of an IGO’s functionality differ. While some states may herald the legal power of the WTO and its intellectual property regime, others may regard this as a health hazard. Or while some states may prefer targeted, vertical disease campaigns as they are promoted by the GFATM, others may favor more integrated approaches to strengthening health systems that are part of WHO’s policy portfolio. Therefore, it also matters who of several contending actors has the means to actually choose exit, such as because a state can do without the collaboration of its partners within an established IGO, or because it has the means to establish and strengthen a rival institution. Usually, functionality and power concerns will interact in decisions about exit. This interaction is illustrated by a prominent example of exit in the global health domain, namely the history of the Joint United Nations Programme on HIV/AIDS (UNAIDS). AIDS, which emerged in the 1980s, was initially dealt with by a special unit inside WHO, the Global Programme on AIDS (GPA). In its early years the GPA was supported by a strong coalition of activists, NGOs, and Western donor states. It attracted enormous funds, which it administered directly with donors and recipient countries instead of working through WHO’s regional offices. Yet over time internal and external resistance to the GPA grew. From inside WHO, a leadership change led to a greater voice for WHO’s regional offices and to measures that aimed to rein in the relative autonomy

Politics of Intergovernmental Organizations   359 of the GPA (Hanrieder 2014b). From the outside, states and other IGOs pressed for a more inter-sectoral scheme for the global response to HIV/AIDS, a pandemic that preoccupied many IGOs due to its dramatic impact on health and human development (Morse and Keohane 2014, 404–405). The outcome of these struggles was the creation of a new UN umbrella organization for HIV/AIDS in 1995 (UNAIDS) to coordinate the AIDS-related activities of the entire UN system, from the UN Population Fund to UNESCO (see note 1). At the time UNAIDS was more responsive to demands by powerful players, and it satisfied expectations of functionality by offering a truly inter-sectoral scheme of UN-wide collaboration. While it is debated whether UNAIDS has indeed assumed the coordinating role foreseen for it, it has undoubtedly found its role as an advocate and campaigner for the combat of HIV/AIDS (Morse and Keohane 2014, 405). The case of UNAIDS is also an example of a wider controversy about the consequences of exit and organizational proliferation for global health governance. In the global health literature, the tone about institutional density tends to be negative. The duplication of activities and lack of coordination that accompany competition, and thus the absence of an ‘architecture’ that bundles the resources for global health, are often bemoaned by global health scholars (Fidler 2007). In the global health domain, this lack of architecture is not least attributable to the fact that WHO’s ability to assume its constitutional role as the coordinating and directing international health agency is at best varied. It is weak, for example, in the domain of health aid, where recipient countries are often confronted with a huge number of donors and aid providers, which leads to high coordination costs and potential policy incoherence (Cohen 2006). It is stronger in the domain of knowledge creation and standard setting. With soft but efficient means, WHO ‘orchestrates’ the generation of expert consensus thanks to its convening power and its network of scientific collaborating centers around the globe (Hanrieder 2015b). But even in this domain, challengers are arising, for example the BMGF-sponsored Institute of Health Metrics and Evaluation, which produces its own public health statistics that rival the expertise of established IGOs (Smith 2015). And also in the field of health security, in which WHO has been empowered to act as a hub of surveillance and containment activities (Zacher and Keefe 2008), its leadership is put into question. For example, WHO’s coordination of the emergency response to the 2014 West African Ebola outbreak created dissatisfaction among states (Kamradt-Scott 2016). It led to the creation of the first-ever health-related UN mission, called UN Mission for Ebola Emergency Response (UNMEER). In the aftermath of this Ebola epidemic, new funds and provisions for health emergencies were introduced not only within WHO but also within the World Bank. WHO created the Contingency Fund for Emergencies, and the World Bank the Pandemic Emergency Financing Facility.7 Such constantly emerging parallel structures in global health may confirm the skeptical view that the field of global health IGOs is ripe with duplication and harmful conflict between institutions. However, a more optimistic view of the aggregate outcome of IGO overlaps suggests that IGOs can also complement each other. Faude (2015) develops such an argument for the well-known case of regulatory conflict over intellectual property rules in health policy. These conflicts became acute with the entry into force of the

360   Tine Hanrieder TRIPS Agreement in 1995. The agreement, which is binding on all members of the WTO, jeopardized developing countries’ ability to produce and trade generic medicines. WHO was a main arena in which the critics of the TRIPS Agreement managed to push for clearer public health safeguards, which were enshrined in the 2001 Doha Declaration and a 2003 TRIPS amendment. According to Faude, this shows that a ‘division of labor’ has emerged among WHO, the World Intellectual Property Organization (WIPO), and the WTO. WHO and WIPO advise countries on how to adopt TRIPS-compatible public health measures, and WTO dispute settlement forges coherence between different regulations. Faude suggests that this emerging order is indicative of a broader pattern, because states always have an interest in maintaining some compatibility between rules, so that inter-institutional conflict will normally be transitory and not permanent. In fact, a division of labor is also envisaged for the two emergency funds managed by WHO and the World Bank. While WHO fund is tailored to the immediate reaction to disease outbreaks at an early stage, the World Bank fund will provide additional aid once a health crisis has reached a certain stage of severity.8 These observations suggest that health-related IGOs do not operate in isolation but within whole IGO ecologies. Thus, to understand the governance of global health issues, we need to understand how different IGOs take each other into account when designing their programs. Going one step further, one may even suggest that the formal separation between different IGOs, or between IGOs and their state, and the NGO environment is to some extent artificial. The fact of revolving doors, with myriad global health experts constantly moving back and forth between different domestic and international, public, and private global governance institutions, also blurs the boundaries between these organizations and leads to the emergence of dense interpersonal networks across organizations (Seabrooke and Tsingou 2009; Holzscheiter and Pantzerhielm 2016). For the research on health-related IGOs, this raises the question of how elite networks and discourse coalitions produce or also transcend boundaries between individual IGOs and renegotiate their competing or complementary policies.

Conclusion IGOs continue to play an important part in the provision of global health governance. They are not only instruments of powerful member states, but also authorities in their own right, shaping the meaning and practice of healthcare around the globe. States and social actors will keep turning to IGOs when seeking support in the face of old and new health challenges; in doing so, they will often rely on the cognitive tools and political categories provided by IGOs. The different research strands reviewed in this article underline the dynamism of health-related IGOs, but at the same time demonstrate the continued effects of early institutional choices made in the nineteenth and twentieth centuries. The result is a complex interaction between institutionalized patterns and demands for change that will continue to stimulate innovation in global health and IGO research.

Politics of Intergovernmental Organizations   361 It is also clear from this review that IGOs rarely operate in isolation. Individual IGOs such as WHO are embedded in complex networks of IGO, state, and nonstate actors. They have to take into account not only the activities of their IGO peers, but increasingly also those of nonstate actors and philanthropists, who to some extent rival the agenda setting and coordinating power of traditional IGOs (see the chapter by Youde in the volume). These developments invite both comparisons between the workings of private and public authority in the field of global health and studies of the intermingling of these spheres in the emerging inter-organizational ecologies of health authority beyond the state.

Notes 1. For this definition see Rittberger, Zangl, and Kruck (2012, 8). Note that the multilateral act can also be indirect, namely in meta-organizations that are formed by one or several already existing IGOs. An example of a meta-organization in global health is the Joint United Nations Programme on HIV/AIDS (UNAIDS), which was founded in 1995 by six UN organizations: the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF), the United Nations Development Programme (UNDP), the United Nations Population Fund (UNFPA), the United Nations Educational, Scientific, and Cultural Organization (UNESCO), and the World Bank. 2. DDT (dichlorodiphenyltrichloroethane) is an insecticide used in malaria control. 3. See http://independentwho.org/en/. 4. See http://www.who.int/csr/disease/ebola/panel-to-assess-response/en/. 5. An exception is the European Commission, which participates as a voting member; see http://www.theglobalfund.org/en/board/members/. 6. See http://www.gavi.org/about/governance/. 7. Garrett (2016) expresses doubts regarding the seriousness of states’ commitments to contributing their share to these funds. 8. See http://www.who.int/about/who_reform/emergency-capacities/contingency-fund/en/. The World Bank makes explicit reference to the relationship between its own and WHO’s emergency fund; see http://www.worldbank.org/en/topic/pandemics/brief /pandemic-emergency-facility-frequently-asked-questions.

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chapter 19

Ci v il Societ y a n d Gl oba l H e a lth Politics David M c Coy and Joseph Gafton

There is much reference in the health literature to the role of ‘civil society’ in providing healthcare or campaigning for particular health needs. Civil society representatives are also deemed essential to global health governance (GHG). However, rarely is the presence of ‘civil society’ in global health discussed as a political phenomenon. This chapter seeks to fill this gap in the health literature by assessing both the political role of civil society actors in global health and how civil society itself is shaped by prevailing power structures and ideologies. It first discusses the concept of civil society, then notes the importance of ‘neoliberal globalisation’ in forming the political context for civil society’s participation in global health. It then describes the political nature of civil society’s participation in global health through three interconnected topics: (a) the difference between conservative and radical visions of health, (b) the evolution of GHG structures and systems, and (c) the corporate capture of philanthropy and civil society. It ends with some concluding remarks and a look to the future of global politics and civil society.

The Concept of Civil Society Civil society is typically understood in two ways. First, as a collection of actors that share the distinction of being neither governmental nor a business or other form of commercial organisation. Second, as one of three spheres of society, alongside the state and the market. While seemingly simple and straightforward, both understandings of civil society are more complex.

368   David McCoy and Joseph Gafton To begin with, civil society actors are extremely diverse in nature. They may include professionalised non-governmental organisations (NGOs), charities, universities, independent research institutions, think tanks, professional associations, trade unions, cooperatives, faith-based organisations, consumer groups, community-based sports and leisure clubs, and more loosely organised social movements. Furthermore, they are extremely diverse in terms of their functions, size, membership, and geographic affiliation (McCoy and Hilson 2009). The governmental and private sectors are also diverse in nature. The former includes the executive, legislative, and judicial branches of government, as well as other organs of the state such as the army, the police, and any number of quangos or parastatal agencies. The latter range from tiny micro businesses to large global conglomerates and cut across the financial, manufacturing, agricultural, extractive, retail, and service sectors. Any simplistic distinction amongst the state, markets, and civil society also masks the fact that actors may cut across the three spheres. For example, some NGOs that have the appearance of being part of civil society may have been established and funded by governments or private corporations to act as their agents. Such NGOs have been classified as GONGOs (government-organised NGOs) and BINGOs (business-interest NGOs) to make the point that they are not true civil society actors. This raises questions about the legitimacy and independence of civil society actors. Clearly there is a distinction between broad-based and inclusive civil society actors with a public interest mission and those that exist primarily to serve the interests of governments or private actors (Doyle and Patel 2008). The three spheres of the state, markets, and civil society are also highly interconnected and coexist in different ways depending on the social, political, and economic context of any given society. For example, in authoritarian countries ruled by dictatorships, civil society actors may be weak and the sphere of civil society may be small relative to that of the state, but where democracy is strong, civil society actors may act as a check and balance to the power of the state. Similarly, the character, size, and influence of the market in society will depend on the sociopolitical context. For example, the way in which tax systems are designed and implemented and the way in which legal and judicial systems regulate corporate activity and electoral processes will influence the relative power of the corporate sector and its ability to influence public institutions or democratic processes. Similarly, in societies with unrestrained capitalism and unregulated markets, private interest groups have a greater opportunity to flourish at the expense of the general public. Civil society is also political. Kaldor (2003, 585) describes it as an arena in which individuals and groups ‘negotiate, argue, struggle against, or agree with each other through a variety of associations and organisations’, while Scholte (2011) describes it as a space in which voluntary organisations interact to shape the rules of society. Tarrow (1994) even describes social movements as the central bearers of democratising pressures within states, noting their role in the overthrow of dictatorships in Latin America and Eastern Europe.

Civil Society and Global Health Politics   369 There are many other examples of progressive political change spearheaded by civil society, including the abolition of slavery, the emancipation of women, the defeat of apartheid, and the campaign to reduce the price of treatment for people living with HIV/AIDS. Civic society may also play less overt political roles. For example, civic associations such as community choirs and sports clubs may help cultivate tolerance, trust, and cooperation in society, which in turn can help sustain democracy and social solidarity (Putnam, Leonardi, and Nanetti 1993; Putnam 1995). It is important, however, not to equate civil society with progressive, democratic, and liberal ideals. Civil society extends across the political spectrum and includes anti-democratic, ethnonationalistic movements (Müller 2017) as well as racist groups like the Ku Klux Klan. Civil society is therefore a loose, complex, dynamic, and political phenomenon. It is both a place within which politics is played out and a collection of political actors. The next section looks at the global context of civil society and how neoliberal policy and globalisation have combined to shape civil society’s participation in global health politics.

Neoliberal Globalisation and Contemporary Global Health Politics Neoliberal globalisation has been described as ‘one of the most distinct political developments of the past half-century’ (Bexell, Tallberg, and Uhlin  2010). It has ­produced profound shifts in the balance of power across national and global society, including across the spheres of the state, market, and civil society. In particular, the global integration of markets for goods, services, and finance, as well as the widespread adoption of a neoliberal ideology that champions deregulation, privatisation, and ­market competition, has resulted in the power of transnational corporations (TNCs) and private finance growing at the expense of governments, local businesses, and workers. Neoliberal trade and investment laws have further consolidated the power of transnational corporations and elites at the expense of governments, parliaments, and civil society. Critically, the strengthening of controls on the movement of people across national borders, in conjunction with the liberalisation of cross-border flow of capital, goods, and services, has shrunk the power of labour relative to that of capital (Labonté and Schrecker 2007). The need for countries to weaken labour protection laws in order to attract private investment has further accentuated this power shift, with at least 1.4 billion workers now dependent upon jobs that are precarious (ILO 2017). Meanwhile, by extending and strengthening private property rights and facilitating deregulation, privatisation, and marketisation, governments themselves have helped ‘hollow out’ the state (Milward and Provan 2000) and diminished their own mandate and ability to promote the well-being of society (Harvey 2007; Carroll and Jarvis 2015).

370   David McCoy and Joseph Gafton In parallel, the enablement of transnational corporations and wealthy elites to evade national tax regimes, the removal of tariffs, and the lowering of corporate tax rates have shrunk important sources of public revenue and contributed to unprecedented levels of socioeconomic inequality; while 71 percent of the world’s population lives in poverty on less than US$10/day (Kochhar and Oates 2015), sixty-one individuals (mostly men) own the same amount of wealth as the poorest half of the world’s population (Pimentel, Aymar, and Lawson 2018). Another feature of globalisation has been a shift in the locus of rule-setting and decision-making from the local and national levels to the supranational level. Most of the rules governing the globalised economy have been established under the auspices of the Bretton Woods institutions or through multilateral trade and investment agreements. As a result, many aspects of economic governance now take place in settings and through processes that are shielded from any effective scrutiny of national parliaments and local institutions. Accompanying these broad shifts in power has been the emergence of global publicprivate partnerships (PPPs) as a new form of global governance. Essentially, these are new structures that have been created to enable the participation of non-state actors (NSAs) in decision-making at the global level across a range of sectors. The argument is that PPPs would bypass the inefficiencies of the UN system and create effective global governance by combining the authority of the UN system with the business acumen of the private sector and the social values of civil society (O’Brien 1997; Utting 2000; Kaul 2006). Two important landmarks are the 2004 UN Global Compact, which legitimised and codified the involvement of NSAs in the UN system, and the awarding of observer status to the International Chamber of Commerce (the world’s largest business organisation with more than six million members) in December 2016 to the UN General Assembly, which gives the private sector a direct voice at the highest level of the UN (Brunkhorst and Martens 2016). Changes in the distribution of wealth and political power, as well as shifts in the locus of governance from the national to the global level (and from intergovernmental organisations [IGOs] to PPPs), have had profound impacts on the systems and structures of government and global governance, including in the health sector. The next section looks specifically at the global health sector and discusses the politics of civil society’s role in global health.

Civil Society and the Politics of Global Health This section looks at three key aspects of global health politics: first, the ideological differences between comprehensive and selective primary healthcare; second, the emergence of new actors in the global health landscape; and third, the corporate capture of civil society.

Civil Society and Global Health Politics   371

Comprehensive and Selective Approaches to Health One of the most enduring policy tensions in global health revolves around the ­difference between so-called comprehensive and selective approaches to health improvement. The difference between these approaches is often framed in technocratic terms. However, the two approaches really represent different political and ideological perspectives on health. Taking place on Soviet soil in the midst of the Cold War, the 1978 Alma-Ata Conference set an ambitious vision for global health improvement that came to be known as comprehensive primary healthcare (CPHC). It framed health and healthcare systems as products of social, political, and economic factors (UNICEF and WHO 1975; Cueto  2004). It challenged biomedical power within the health sector; stressed the importance of appropriate technologies; championed the empowerment of communities; and highlighted food security, literacy, clean water, human rights, and peace as critical determinants of health for all. This holistic and multisectoral approach to health became associated with a tagline: ‘health for all by the year 2000’. Crucially, from a global perspective it was rooted in an internationalism that called for a fair and just new international economic order that would correct historical power imbalances and enable development in the world’s many new postcolonial states. However, soon after that a counter current emerged around an approach that came to be known as selective primary healthcare (SPHC). Its proponents argued that CPHC was  utopian and impractical and called for a more pragmatic approach to health improvement that focused on the delivery of a few cost-effective interventions aimed at a selection of disease-specific priorities (Walsh and Warren  1980). It eschewed the  social and political framing of CPHC and instead emphasised the proximal determinants of disease and interventions that could be delivered to passive recipients of healthcare (e.g., vaccines, processed oral rehydration salts, nutrition supplements, and pharmaceuticals). In the end, SPHC prevailed and became dominant in international and global health policy. This dominance was aided by the imposition of neoliberal ‘structural adjustment programmes’ (SAPs) on the developing world by the International Monetary Fund (IMF) and World Bank in the 1980s and 1990s, following a ‘debt crisis’ (Harvey 2007). Public spending, including on healthcare, was slashed as governments prioritised debt repayments and the World Bank implemented health sector reforms that typically consisted of (1) a diminished state aid, bolstered by international aid, providing a minimum package of basic interventions; (2) the encouragement of user fees; and (3) greater emphasis on community self-help. Civil society actors were involved in the promotion of both CPHC and SPHC. Amongst those who developed the vision of CPHC in the 1970s were civil society actors who pioneered community-oriented primary care (Kark and Kark  1983; Mullan and Epstein  2002), the World Council of Churches (Litsios  2004; Bryant and Richmond 2008), and members of an NGO, Committee on Primary Health Care, that

372   David McCoy and Joseph Gafton helped plan the Alma-Ata conference (Rifkin and Walt  1986). The Jubilee 2000 ­campaign—one of the largest transnational civil society mobilisations of the twentieth century—provides another example of civil society’s support for CPHC and a fair international economic order; it campaigned for the cancellation of illegitimate debts that had paved the way for the imposition of SPHC through SAPs and were responsible for devastating the lives of hundreds of millions of people. Today, the Peoples Health Movement (PHM), a global alliance of civil society organisations (CSOs) that was established in 2000 to reaffirm the principles of Alma-Ata, is an example that emphasises the importance of social and political activism to improved health (Narayan 2006; People’s Health Movement 2000). Civil society actors were also involved in establishing SPHC as a countervailing approach to CPHC. In particular, the Rockefeller Foundation played a key role by, amongst other things, sponsoring an international health and population development conference in 1979 that advanced the case for SPHC (Birn and Fee 2013). There was also support from parts of the scientific and medical community that favoured the apolitical and technological emphasis of SPHC. Perhaps more importantly, SAPs and the World Bank’s health sector reforms established an NGO sector that would come to have a vested interest in supporting SPHC. This came about as a result of NGOs being funded to deliver the services of SPHC and fill other gaps left by a shrinking state (Ryan 1999; Dart 2004; Cooney 2006). As a result, a professionalised and large international NGO (INGO) sector grew in the 1980s. INGOs are now a ubiquitous presence in many health systems across the world, but especially in developing countries, where they receive a substantial proportion of development assistance for health (DAH). However, some scholars argue that this ‘NGO-isation’ of development assistance has inhibited and even undermined other forms of civil society, including social movements that seek to improve health through socioeconomic development and political struggle (Eikenberry and Kluver  2004). According to Chandhoke (2009), professionalised NGOs, many based in the global North, have replaced local political agendas with externally imposed plans and projects. A more critical perspective is that the professionalised NGO sector helps ‘to protect the legitimacy and hegemony of the neoliberal project’ (Carroll and Jarvis  2015, 288) by softening or containing dissent (Fine 2002; Harriss 2002) and depoliticising issues such as the illegitimate and unfair aspects of SAPs. The tension between SPHC and CPHC illustrates how CSOs in the global health sector are made up of a range of actors with diverse ideologies and positions with respect to the political economy of health. According to Sparke (2009), CSOs may be categorised into three groups depending on their relationship to neoliberalism: CSOs that act as agents of neoliberalism are described as ‘market fundamentalists’, while ‘market foster-care’ CSOs act to mitigate the deficiencies and harms of neoliberalism, and ‘market failure’ CSOs oppose the neoliberal political and economic arrangements that produce poverty, inequality, and underdevelopment. Similarly, Scholte (1999) distinguishes between ‘conformists,’ who uphold and reinforce existing norms; ‘reformists,’

Civil Society and Global Health Politics   373 who wish to correct flaws in existing regimes while leaving underlying social structures intact; and ‘radicals,’ who seek a transformation of the social and political order.

Global Health Governance and the Rise of New Actors The previous section illustrated how the politics of global health (i.e., the tension between SPHC and CPHC) and the nature of civil society in the health sector (i.e., the growth of a professionalised INGO sector) interact with each other. This section looks at the interaction between GHG and civil society. It shows how developments in GHG have increased the role of NSAs and shaped civil society’s participation in global health, as well as how some civil society actors have in turn shaped the structures and systems of GHG. Three aspects of GHG are highlighted: the weakening of WHO, the rise of global health PPPs, and the emergence of the Bill and Melinda Gates Foundation (BMGF) as a major new global health actor. Although WHO remains important because of its mandate to act as the ‘directing and coordinating authority on international health work’ within the UN system (WHO 2005), it has been weakened (Clift 2013). Financially, it has suffered from budgetary constraints since the 1980s. Furthermore, its independence as a multilateral agency has been undermined by the fact that it is overly influenced by a small number of donors who fund most of WHO’s budget. Only twenty donors made up as much as 78 percent of its total programme budget in 2016–2017; furthermore, about three-quarters of the ­budget consists of voluntary contributions that are tied to specific objectives agreed to by donors (WHO 2016b). WHO has also been weakened by the emergence of new and rival actors on the global health landscape. These include the World Bank (since the early 1980s) and the subsequent emergence of multiple global health partnerships (GHPs). Since 2000 an increasing percentage of DAH has flowed through multi-stakeholder partnerships, governed by boards with representatives from governments, UN bodies, businesses, and civil society (Buse and Walt 2000). Indeed, the combined expenditure of the Global Fund and GAVI Alliance eclipses that of both WHO and the World Bank (Rushton and Williams 2011). The global health landscape has also been transformed by the arrival of the BMGF as a major actor since around the turn of the millennium. Not only did it catalyse the emergence and proliferation of GHPs, it has become a powerful shaper of global health policy and discourse (McCoy et al. 2009). In addition to GHPs, the BMGF funds and influences a range of other global health actors; as well as being the second biggest donor to WHO, it funds a diverse range of other global health actors, including government agencies, universities, research institutes, INGOs, the World Bank, UNICEF, and other private foundations (McCoy et al. 2008). Taken together, these changes in GHG point to a growing influence of NSAs, and in particular the BMGF and GHPs. Five of the current top ten funders of WHO are NSAs: the BMGF, the GAVI Alliance, the World Bank, Rotary International, and the National Philanthropic Trust (a US-based organisation that channels philanthropic funds on

374   David McCoy and Joseph Gafton behalf of private foundations, corporations, and financial institutions). Overall, member states contribute only 51 per cent of total voluntary contributions (WHO 2016b). In the case of GHPs, NSAs are at ‘the decision-making table’, more or less as equal partners of governments and the UN. However, the rising influence of civil society in GHG is socially patterned and strongly influenced by the effects of neoliberal globalisation, as described previously. For example, the pre-eminent position of the BMGF reflects the immense concentration of global wealth and the ability of super-elites to shape global narratives, policies, and programmes. There is also a bias towards certain civil society actors being able to participate in GHG. For example, although any civil society actor can in theory enter into ‘official relations’ with WHO and be allowed to attend the World Health Assembly and petition the director-general to table resolutions and items for discussion (WHO 1987), the prohibitive cost of travel and accommodation in Geneva limits participation mostly to professionalised INGOs from high-income countries that are well funded by donor governments, private foundations, or the corporate sector. Similarly, while GHPs appear to enhance civil society participation in global ­gov­ern­ance in general, a study of eighteen prominent GHPs found that CSOs only occupied about a tenth of all seats—far less than the private sector actors, who occupied a quarter of all seats (Storeng and De Bengy Puyvallé 2018). Furthermore, the study found that most civil society representatives were drawn from the global North and that only 7 out of 274 seats across the eighteen GHPs were held by individuals representing ‘patients’ or ‘affected communities’ in low- and middle-income countries. Storeng and De Bengy Puyvallé (2018) also found that behind the rhetoric of partnership, the role of civil society was mostly limited to supporting the implementation of GHP-led programmes (and their emphasis on narrow and selective services and technologies) or to lobbying and advocating on behalf of those same partnerships. Only a minority of GHPs described the role of CSOs as being to question and shape decisionmaking or to play a transformative role in power structures. Civil society has thus been co-opted to represent GHPs rather than to hold them to account. The tendency of GHPs to focus on one or a handful of diseases or technologies also means that a large segment of civil society actors in global health tend to reinforce the narrow, apolitical, and technocratic values of SPHC. Furthermore, both the BMGF and GHPs reflect a ‘new philanthropy’ that embraces the application of business techniques and market competition to the social domain of health (McCoy and McGoey  2011). These include the use of performance-based funding models by ­donors and the characterisation of charities and NGOs as ‘investment vehicles’ that demonstrate their value in terms of quantifiable social returns. Consequently, a topdown and short-term, results-driven approach has been reinforced across civil ­society, displacing actors that emphasise bottom-up empowerment, cooperation, and longer-term institution building. As CSOs compete with each other and strive to prove their value to donors, they become less responsive and accountable to the ­communities they serve.

Civil Society and Global Health Politics   375

Corporate Capture of Civil Society A crucial point about the widening participation of NSAs in GHG is that it has extended the influence of commercial actors in global health. Under the guise of partnerships, powerful market actors are better able to influence global health policy and benefit in various ways. For example, GHPs provide an opportunity for pharmaceutical corporations to expand their own markets by directing public and philanthropic funds towards commodities such as pharmaceuticals and vaccines. Involvement in UN-backed health programmes also provides a platform and favourable publicity to enable corporations to block proposals to strengthen the regulation of markets and corporate practises. The importance of growing corporate influence in GHG becomes clear when considering the fact that much of the current global burden of disease relates to risk factors that are manufactured and supplied by multinational corporations (Stuckler et al.  2012). These include tobacco, alcohol, sugar, junk food, weapons, and fossil fuel, of which a large amount of consumption is supplier induced. Although WHO has the Framework for Engagement with Non-State Actors (FENSA), designed to protect and preserve its integrity and reputation (WHO 2017) by, amongst other things, disallowing individuals from private companies from taking up WHO secondments and prohibiting tobacco and arms companies from any engagement with WHO (WHO 2016a), collaboration with private companies that have conflicts of interest is permitted. This includes alcohol, food, and pharmaceutical corporations influencing and even shaping policies taken to tackle the problems caused by alcohol, junk food, and overpriced medicines (Medicus Mundi International  2017; Rached and Ventura 2017). The BMGF—which is a type of civil society actor—is also important in legitimising the increasing involvement of private corporations in global governance. As well as having to close links to the pharmaceutical, technological, and food and beverages sectors, Bill Gates is a strong advocate of capitalism as a solution to poverty and of the view that social problems can be best solved by harnessing the entrepreneurial and profitmaximising instincts of the private sector (Bishop and Green  2008; Ponte and Richey 2014; McCoy and McGoey 2011), including through ‘cause-related marketing’ initiatives in which the consumption of corporate products or services is linked to NGOs or charities with social objectives (Grau and Folse 2007). The involvement of NSAs in governance and the blurring of philanthropy with capitalism are important dimensions of GHG that benefit market actors, especially those that are large and powerful. However, corporations employ an array of other tactics designed to maintain corporate-friendly and liberal economic systems. These include direct lobbying of politicians and officials, funding election campaigns, facilitating a ‘revolving door’ for personnel to move between industry and government, and allowing industry lobbyists to be appointed to regulatory agencies (Stuckler, Basu, and McKee 2011). Another tactic has been to capture and influence the voice of civil society.

376   David McCoy and Joseph Gafton The corporate capture of civil society is done in various ways. These include the c­ reation and funding of NGOs and other front groups to further corporate interests. Examples include consumer and patient groups who are funded by the pharmaceutical industry to lobby governments to spend more money on profitable medicines (Ball, Tisocki, and Herxheimer,  2006; Marshall and Aldhous  2006). Similarly, the NCD Alliance, which is described amongst other things as a ‘global thought leader on NCD policy and practise’ and ‘convener of the civil society movement’ (NCD Alliance 2018), includes corporate partners and receives funding from the pharmaceutical and medical devices industry (Gopakumar and Third World Network 2017). Corporations also use their power to shape public attitudes. For example, to oppose the Framework Convention on Tobacco Control (FCTC) tobacco companies used PR campaigns to ‘reframe’ public discussion away from the harms and addictive properties of tobacco towards narratives about the virtues of consumer choice and the threat of ‘big government’ (Weishaar et al. 2012). Similar tactics are being deployed to stave off government intervention in the food and alcohol industries (Gilmore, Savell, and Collin 2011; Stuckler and Nestle 2012). Finally, corporations also take active measures to capture academic, scientific, and intellectual voices to undermine or distort evidence that may be detrimental to their interests (McGarity and Wagner 2008). For example, although the UK-based Social Issues Research Centre (SIRC) describes itself as an ‘independent, non-profit organisation’, it draws funding from Coca-Cola, Masterfoods, and GlaxoSmithKline while publishing articles that question the idea of an obesity epidemic (Miller and Harkins 2010). If the science cannot be captured, the strategy is to create uncertainty to block meaningful policy change (Michaels  2008). Researchers and ‘think tanks’ have similarly been funded by the oil industry to cast doubt upon climate science (Monbiot 2006; Hamilton and Downie 2007).

Conclusion Discussions about the role of CSOs in global health more often than not focus on their functions and comparative advantages vis-à-vis the state and market. Often civil society, government, and the private sector are presented as the separate legs of a stool upon which effective GHG and vital cross-national or inter-sectoral alliances are established (Smith, Buse, and Gordon 2016). In this tripartite conceptualisation of governance, civil society actors are often viewed as ‘gap fillers’, occupying spaces that have been vacated by the state or neglected by the market. Civil society is also often characterised as providing a perspective that is different from the state or market. For example, Horton eulogises civil society actors for ­providing ‘essential voices in discordant global conversations that are often dominated by risk-adverse multilaterals, corrupt governments and neo-colonial donors’ (Horton 2016). This perspective is often accompanied by an implicit assumption that civil society

Civil Society and Global Health Politics   377 actors represent the interests and needs of communities most affected by poverty and global challenges. However, as discussed previously, civil society is spread across a wide spectrum of social and political perspectives and includes actors who are reactionary and serve the interests of the powerful and wealthy. Furthermore, any representation of a neat and simple three-way segmentation of society is a myth that hides the more complex reality of cross-cutting political alignments and the uneven distribution of power across society as a whole. We suggest that Sparke’s and Scholte’s three-way categorisation of CSOs is a useful heuristic device for both highlighting their heterogeneity and understanding civil society’s relationship to neoliberal globalisation and its profound impact on society. Through this categorisation, civil society actors may be classified as being (a) ‘conformists’ or market fundamentalists, who uphold, reinforce, and extend neoliberal policies and norms; (b) ‘reformists,’ who work to mitigate the harms of neoliberalism while leaving underlying power relations and social structures intact; or (c) ‘transformists’ and radicals, who challenge the underlying political and economic causes of poverty, inequality, and poor health. In this framework, BINGOs and philanthrocapitalists may be classified as neoliberal conformists or market fundamentalists, while most INGOs would be classified as reformists, substituting for the deficiencies of hollowed-out states, providing welfare to those living on the margins of the global economy, and working through global alliances to promote the adoption of instruments such as international humanitarian and human rights law to mitigate the unfair social and economic effects of globalisation (UNDP 2002, 106). However, some civil society actors are ‘transformists,’ with a more ambitious and radical agenda. These might include the PHM, which has consistently advocated for a return to the radical and progressive vision of CPHC and provided an explicitly ­anti-neoliberal critique of global health and GHG (Kapilashrami and Schrecker 2018). And there are, of course, thousands of civil society groups who are resisting the structural violence of neoliberal globalisation and adopting more confrontational modes of action that may include consumer boycotts, strike action, civil disobedience, and revolutionary struggle. According to a survey of ‘world protests’ between 2006 and 2013, there is evidence of an increase in civil unrest since 2010 against aspects of the prevailing political and economic order, including the collapse of public services, tax injustice, unemployment, deteriorating labour conditions, inequality, poverty, land reform, food and energy prices, militarism, and environmental degradation (Ortiz et al. 2013). But while such protests exist in their hundreds at a local level, the civil society actors involved in them tend not to be heard or seen in global forums. A key message of this chapter is that civil society both reflects and shapes wider power dynamics in society. When it comes to global health, the rise in the number and type of actors may give the impression of a more diverse, open, and democratic approach to governance and decision-making. However, most CSOs with influence in global forums

378   David McCoy and Joseph Gafton tend to either represent powerful and hegemonic interests (Bebbington, Hickey, and Mitlin  2008) or limit the degree of debate about policies and programmes so that existing power relations are not challenged. Critically, the funding of CSOs by private foundations, donor states, and corporations has resulted in certain NGOs, often headquartered in the global North, dominating the civil society space at the global level. Civil society actors with a more progressive and transformative agenda are less visible and lack the funds and opportunities to influence policy. The national dimension to global health politics is also important. The capacity for large segments of the world’s population to influence global policy through their governments is curtailed not just by the shrinkage of sovereign state power but also by the capture or corruption of democratic institutions by powerful and wealthy actors. Thus, while there have been many progressive civil society campaigns on a wide range of issues, unbalanced power relations and democratic deficits prevent many of the injustices and social problems of globalisation from being effectively addressed (Ortiz et al. 2013). As far as the structures of GHG are concerned, a key challenge for ensuring a more democratic and accountable system would include restoring WHO’s status as a global health authority with a mandate to act as a global public institution serving the needs of all peoples. While PPPs have been viewed as a mechanism to do this, others question whether they amount to a semi-privatisation and commercialisation of the UN system (TRAC 2000; Richter 2003). The restoration of WHO’s independence and integrity as an intergovernmental technical agency would require several internal reforms and improvements in management, but crucially, it would require changes to the way WHO is financed, the removal of all conflicts of interest with NSAs that have commercial or narrow interests, and the establishment of mechanisms by which CSOs with broad-based public-interest ­missions can both scrutinise and support WHO. Another challenge is curtailing the power of corporations. The importance of this is clear from the scale of harms posed by tobacco, junk food, tobacco, and overpriced medicines, as well as by the willingness and ability of oil and weapons companies to perpetuate global warming and armed conflict. Civil society actors will need to play an important role in protecting populations from the harms caused by corporate behaviour, just as they did in restricting the damage caused by tobacco and milk powder companies (Mamudu and Glantz 2009; Lencucha, Kothari, and Labonté 2011; Collin, Lee, and Bissell 2002; Allain 2002; Lee 2010) and in pushing back against pharmaceutical monopoly rights that prevented access to antiretroviral treatment for people living with HIV/AIDS (Smith and Siplon 2006; ‘t Hoen et al. 2011). But the size of the challenge of overcoming corporate power and correcting the global democratic deficit is considerable. An open-ended intergovernmental working group established by the UN to work on an international legally binding instrument to regulate, in international human rights law, the activities of transnational corporations and other business enterprises (Office of the United Nations High Commissioner for Human Rights 2014) offers one mechanism by which the rules of global finance and trade can be rewritten to reduce inequality, promote health, and protect the environment.

Civil Society and Global Health Politics   379 The environmental crisis and its threat to all of humanity offers another opportunity to mobilise the social and political will to restore democracy and build a fairer economy. The prospect of the collapse of any organised human civilisation is now very real. However, any hope of preventing widespread, catastrophic climate change will require society to wrest power and privilege away from oil companies and other actors who actively seek to undermine social and democratic stewardship of the planet and economy. However, it will be just as important to avoid the wrong response. Rising inequality, coupled with vast and growing levels of economic and ecological insecurity, is fuelling a growth in populist and anti-democratic nationalism and social violence. The last decade has seen a growth in authoritarian and fascist movements, including in Western liberal states, many of which are expressing antiglobal sentiments and using the resentment of people towards an economic system that works for the few to establish undemocratic and coercive regimes. Rodan (2012) describes how many regimes are bolstering their surveillance initiatives and domestic security agendas, while the International Center for Not-for-Profit Law (2016) has reported an increase in the number of countries considering or enacting measures to restrict civil society. Rutzen (2015) describes civil society as having been ‘under assault’ since the turn of the millennium, while Kaldor (2003) views the US response to 9/11 as a strategy to reimpose a state-based foundation for global governance by closing down the space for more pluralistic and open forms of governance. These observations are consistent with reports of a general decline in democracy worldwide. According to the 2017 Freedom in the World report, 2016 was the eleventh consecutive year of a decline in global freedom (Freedom House 2017). Another recent development has been the impact of the growing interconnectivity of Web 2.0 and mobile technology on civil society. According to Castells (2008), these developments have created new forms of social networks that ‘exist independently from political institutions and from the mass media’ and now bypass many of the traditional avenues of global civic engagement such as those mediated through structured and hierarchical NGOs. While these developments enable civil society to transcend national boundaries at low cost (Seo, Kim, and Yang 2009) and participate in new forms of digital activism (Bennett 2012), the hope that they will strengthen democracy and improve understanding and social relations across territorial and ideological boundaries is now being questioned. Instead, there are growing concerns about the potential for digital technology to erode personal and civil liberties, especially in light of the monopolisation of mobile technology and social media platforms. There are also concerns that social activism and political mobilisation are being replaced by a more shallow and perfunctory form of digital expression or ‘clicktivism’ that may appear to build social solidarity when it actually has the effect of dividing populations into separated communities and echo chambers. Instead of breaking down barriers, new forms of social media have accentuated divisions in society and isolated individuals to interact mainly with those who agree with them, often on the basis of personal emotional identifications and rationales (Sunstein 2007; Karpf 2010).

380   David McCoy and Joseph Gafton Overcoming the various challenges described here will require progressive civil society actors to perform multiple functions. These include a political function aimed at reclaiming and redistributing power and agency across global society and holding governments and IGOs to account; a normative function aimed at upholding certain cultural, moral, and ethical perspectives; an intellectual function aimed at producing new ideas and alternatives to both neoliberalism and authoritarian populism; an educational function aimed at informing and democratising policy debates; and a monitoring function aimed at holding the state and the market to account. For global civil society actors working in the health sector, the challenge will be to confront the issues of global inequality and ecological degradation while simultaneously addressing the effects of disease and illness. Put in other words, it means reembracing the progressive principles and ambitious vision of Alma Ata.

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chapter 20

The Role of th e Busi n ess Sector i n Gl oba l H e a lth Politics Kelley Lee and Julia Smith

The increasing prominence of the business sector has been a defining feature of global health politics since the late twentieth century. There is now a substantial literature documenting the growth in scale, scope, and nature of activities by the business sector in a wide range of global health issues during this period (e.g., Buse and Walt 2000; Richter 2004; Stuckler and Siegel 2011; Freudenberg 2014; Kenworthy, MacKenzie, and Lee 2016). Importantly, alongside increased participation in global health activities (as producers of health-related goods and services, occasional contractors, and charitable donors), the business sector has become a major shaper of, and even participant in, policymaking. This expanded political influence has generated much scholarly and policy debate (Wiist 2010). Some argue that the business sector is a much-needed contributor of financial resources and expertise to, and thus a welcome stakeholder in, global health politics. Others raise concerns about the appropriateness of private, for-profit actors in the pursuit of public interests and even about fundamental conflicts of interest, such as when goods and services are harmful to health. This tension, potential blurring, and risk of co-option of public by private interests has become a central battleground in global health politics. This chapter begins by defining the business sector within the context of global health. We describe the close relationship between the public and private sectors as one of the defining features of global health politics. This is followed by a brief review of the increased scope and scale of business sector activities relevant to global health since the late twentieth century. The focus of the remainder of this chapter is on how these activities have changed the ways the business sector has engaged with global health politics. We discuss three sites where this has occurred: collective action to regulate health-harming

388   Kelley Lee and Julia Smith industries; activities to provide for public interest needs; and perhaps most significant, participation in decision-making that influences global health policies. Analysing the greater extent of engagement by the business sector and what this tells us about the substantial power and influence of the business sector in global health politics is the central purpose of this chapter.

Definition of the Business Sector in Global Health There is a lack of precision in the global health literature regarding the nature and scope of the business sector. In this chapter we use the term business sector as distinct from the broader term private sector. The private sector consists of those components of a society that are not a direct part of, or under the control of, government. The private sector can be divided into for-profit and not-for-profit organisations. For-profit organisations, in which profits are earned for the private benefit of owners or shareholders, can be defined as the business or commercial sector (Lee, Hawkins, and Wiist 2016, 6). Box 20.1 sets out the main types of organisations that seek to earn profits, or a return on investment, as part of the business sector (Buse and Lee 2005, 6). Economic globalisation since the 1990s has brought rapid consolidation of ownership in many industries relevant to health, resulting in many corporations growing to unprecedented size and reach (Freudenberg 2014). As major producers of health-related goods and services, large transnational corporations (TNCs) now control substantial economic resources. By virtue of these resources, large corporations also exert significant political power, either directly or through organisations that advocate on their behalf. Thus the definition of the business sector used in this chapter includes industry

Box 20.1  Selected Types of Organisations in the Business Sector A company or firm is defined as a commercial organisation that operates on a for-profit basis to sell goods or services to consumers. The most common forms of companies are: sole proprietorship—a business owned by a single individual who is legally responsible for its operations. partnership—a business owned by two or more individuals who are legally collectively responsible for its operations. corporation—a business owned by shareholders according to the percentage of stocks or shares held. Sole proprietorships and partnerships do not have legal existence apart from the owners. Corporations do have legal status, which is separated from owners as a protection from direct financial liability. While sole proprietorships and partnerships are the most common forms of companies, corporations are the most relevant to global health politics.

Business Sector in Global Health Politics   389 associations; chambers of commerce; legal, accounting, and public relations firms; business consultancy firms; and lobbyists (Wilks 2013). Importantly, in this chapter we recognise the ambiguity of certain types of organisations that inhabit a grey area between public and private interests. These include charitable trusts and private foundations, think tanks, and advocacy groups. This is because their stated purpose is to serve the public interest rather than making a profit, even though their activities may be funded from the proceeds of for-profit organisations (e.g., endowments created from donated corporate profits, financial returns earned from invested endowments, corporate social responsibility donations). Furthermore, some argue that the work of private foundations sustains a capitalist market system, which in many ways creates the structural conditions in which social inequities and injustice persist (Edwards 2009; McGoey 2012; see also Youde in this volume for a discussion of the role of charitable foundations). There is also growing recognition of the role of think tanks, research institutions, and industry-funded advocacy groups, which are officially not-for-profit in status but may receive substantial funding from for-profit entities as third parties to promote the interests of the business sector. The strategic (and sometimes obscured) use of third parties by the business sector deserves greater scrutiny, but it has been hindered by a lack of transparency regarding funding links and undeclared conflicts of interest by third parties. We discuss the role of third parties in this chapter as an important channel through which the business sector may seek to influence global health politics.

The Increasing Role of the Business Sector in Global Health The history of international health cooperation, dating from the mid-nineteenth century, is closely intertwined with measures to protect powerful interests within the business sector. The fourteen International Sanitary Conferences, held from 1848 to 1938 to agree on shared standardised measures to control the spread of certain epidemic diseases, failed to reach agreement on some practises (e.g., quarantine) because of their potential interference with commercial shipping. As Aginam (2005, 62) writes, Ignorance of the aetiology of cholera, which polarised delegates at the 1851 conference, breathed new life into the ancient debate between the public health theories of ‘miasism’ and ‘contagionism’ as modes of transmission of disease. The divergent views expressed by delegates deeply interlocked with the overall commercial interests of participating countries….Quarantine, whether at the national or international level, were going to hurt their shipping interests.

By the early twentieth century the potential benefits to American capitalism from international health cooperation were an important factor behind the birth of industrialist-led

390   Kelley Lee and Julia Smith philanthropy. In 1913 John D. Rockefeller used wealth generated by the petroleum monopoly Standard Oil Company to form the Rockefeller Foundation. While it supported an array of charitable activities across many countries in pursuit of its mandate ‘to promote the well-being of mankind throughout the world’, the company’s campaigns to eradicate diseases such as hookworm, malaria, and dengue and yellow fever also served its ambitions to extend its foreign markets (Doran, 2016; see also Youde in this volume for more recent examples of philanthro-capitalism). During the twentieth century the business sector also expanded its role in the production of healthcare-related goods and services in most national economies. This was especially the case in countries with privately funded and delivered healthcare systems (Moses et al. 2013). Even where publicly funded and delivered healthcare systems were established, notably in Europe after World War II, private for-profit businesses came to play an important role in the production of medical supplies and equipment, pharmaceuticals and therapeutics, and other healthcare-related goods and services (de Wolf and Toebes 2016). We examine this changing role of the business sector in global health politics since the late twentieth century, a change influenced by the acceleration of economic globalisation in the three most prominent domains: (a) collective action to regulate health-harming industries, (b) voluntary contributions to the public interest, and (c) participation by the business sector in global health governance.

Collective Action to Regulate Health-Harming Industries The marked rise in non-communicable diseases (NCDs) (e.g., hypertension, cancers, coronary heart disease) since the late twentieth century has been widely associated with profound changes in human diets, lifestyles, and environments on a worldwide scale. These changes in turn have been attributed to ‘late stage capitalism’, characterised by the dominance of large TNCs, increased socio-economic inequalities, and large-scale environmental degradation. The business sector has been studied as a major driver of  this rapid and widespread epidemiological transition, most directly through ­market-driven changes in the production and consumption of health-harming products, leading to the formation of global value chains, greater economies of scale, downward pressures on input costs and pricing, and intensified marketing and promotion (e.g., Freudenberg 2014). The resultant ‘industrial epidemics’ (Moodie 2013) or ‘sick societies’ (Stuckler and Siegel 2011) have prompted efforts to strengthen regulation of these industries to protect population health. The ensuing clash between public health advocates and corporate interests has become a central battleground in global health politics. One of the most prominent of these clashes has been the ‘tobacco wars’, waged since the 1960s, when the scientific evidence about the harmful health effects of smoking began to be widely accepted (Brandt 2007). As governments in industrialised countries, the traditional markets of tobacco companies, began to adopt stronger regulation, resulting in a gradual but steady decline in consumption, the industry turned to ‘emerging markets’, largely in low and middle-income countries (LMICs). The pursuit of new

Business Sector in Global Health Politics   391 markets to compensate for declining revenues also led to the global consolidation of ownership within the industry into a small number of large transnational tobacco companies (TTCs). With their substantial economic resources and generating large tax revenues for many governments, TTCs exerted substantial and wide-ranging political influence, including trade pressure to open new markets, lobbying against stronger regulation (such as public smoking bans and standardised packaging), and undermining the legitimacy of public health advocates (Holden and Lee 2009). Given substantial evidence of the tobacco industry’s long-standing efforts to undermine public health research and policy, article 5.3 of the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) requires state parties to adopt measures to protect public health policies from commercial and other vested interests of the tobacco industry. The global politics of tobacco control, which explains how an industry that kills seven million people annually has continued to profit and flourish, is analysed in detail by Lee (in this volume). Evidence of the extensive tactics used by TTCs to market health-harming products and exert political influence has raised similar questions about other industries associated with ‘industrial epidemics’. WHO estimates that alcohol consumption causes 3.3 million deaths annually (5.9 percent of total deaths) as a consequence of more than two hundred disease and injury conditions (WHO 2015). There is growing evidence, for instance, that the alcohol industry has engaged in similar strategies to oppose stronger regulation at the national level such as increased taxation, marketing restrictions, higher drinking ages, and minimum pricing (Baggott 1986; Giesbrecht 2000; Hawkins, Holden, and McCambridge 2012). Over the past thirty years the industry, which has annual revenue of US$1200 billion, has consolidated into fewer and larger transnational alcohol companies (TACs), seeking to extend their commercial reach worldwide (Institute of Alcohol Studies 2016). This has been supported by the industry’s creation of ‘social aspects organisations’, tasked with representing the industry’s position in policy debate and public discourse. In effect, these organisations have opposed stronger regulation of the industry and promoted policies ineffective at reducing harmful alcohol use (Babor 2013). While these efforts have so far focused on high-income countries, where the largest alcohol markets exist, TACs have also begun to expand into emerging markets. Casswell (2013) argues that the alcohol industry has not received as much scrutiny as tobacco to date partly because of campaigns highlighting the possible health benefits of moderate consumption. Efforts to strengthen collective action across countries on alcohol control led to the 2010 WHO resolution to adopt the Global Strategy to Reduce the Harmful Use of Alcohol. Recommendations included limiting availability, minimum pricing, and restricted marketing targeted at adolescents and heavy drinkers. While the strategy suggests that WHO supports stronger regulation akin to tobacco control, given the substantial health harms caused by alcohol, as a strategy rather than a treaty, its national implementation remains limited, with sixty-six member states reporting the adoption of national alcohol policies (WHO 2014b, 62). In response, the industry-funded International Center for Alcohol Policies (ICAP) (representing eleven of the largest producers and two trade

392   Kelley Lee and Julia Smith associations) called for an alternative strategy in 2012, targeted at eliminating ‘negative’ and promoting ‘positive’ drinking patterns (ICAP n.d.). ICAP also argued that producers are ‘equal stakeholders’ who should be involved in formulating global alcohol strategies. There is also evidence of the alcohol industry’s strategic use of ‘harm reduction’ as a tactic to fend off stronger national regulation and collective action on the issue (McCambridge et al. 2014). Given evidence of the industry’s ‘producing scholarly publications with incomplete, distorted views of the science underlying alcohol policies; pressuring national and international governmental institutions; and encouraging collaboration of public health researchers with alcohol industry–funded organisations and researchers’ (Jernigan 2012), more than five hundred public health professionals, chief scientific officers (CSOs), and researchers published a statement of concern addressed to WHO Director-General Margaret Chan, highlighting the weak provisions and enforcement mechanisms embedded in ICAP’s strategy (Babor et al. 2013). Heeding calls to resist industry influence, similar to the approach taken towards the tobacco industry, Chan responded that, ‘[i]n the view of WHO, the alcohol industry has no role in the formulation of alcohol policies, which must be protected from distortion by commercial or vested interests’ (2013, f1889). While regulating tobacco use at any level, and alcohol at excessive levels, is widely recognised as necessary to protect against health harms, the necessity to consume food poses a different regulatory challenge. Concerted efforts to collectively regulate the health impacts of the food sector date from the 1980s, when CSOs campaigned on the marketing of breast milk substitutes, notably in LMICs. Food manufacturers targeted new mothers using, for instance, free samples, sales staff dressed as health workers, and other unethical practises (Zelman 1990). The consequent rise in formula feeding throughout the developing world was linked to increased infant morbidity and mortality, due to parents’ limited access to clean water, knowledge of safe feeding practises, and the relatively high cost of formula (Sethi 1994). A coalition of CSOs, the International Baby Food Action Network, formed to campaign against manufacturers, notably Nestlé, prompted the adoption of the WHO-UNICEF International Code of Marketing of Breastmilk Substitutes in 1981 (Zelman 1990). The campaign gained the broad support of church groups, health professionals, celebrities, and politicians, and generated substantial negative public opinion for the companies involved. At the time, the code was heralded as the culmination of a successful campaign against ‘Big Food’. After initially arguing that the industry was only required to abide by relevant national policies, a stance that allowed manufacturers to exploit weak regulatory environments in many LMICs (Lee 2010), Nestlé stated that it would abide by the international code. Since the 1980s, however, the voluntary nature of the code has limited the capacity of CSOs to monitor corporate activities, and official endorsement by only thirty-seven countries by 2014 has weakened its regulatory effectiveness (Balch 2014). In 2010 five hundred violations in forty-six countries were recorded (Kean 2014). Since the 1980s efforts to regulate the food industry have become central to global health politics. Accelerated globalisation since the late twentieth century has led to fundamental changes to the production and consumption of food worldwide, from ‘plow to

Business Sector in Global Health Politics   393 plate’. These changes include the consolidation of ownership in large TNCs operating on an increasingly global scale (Williams and Nestle 2017). Fierce competition amongst major producers has pressured companies to achieve greater economies of scale, lower input costs, create new products, intensify marketing, and achieve higher profit margins through value-added processing of food commodities. The food industry has argued that changes in food production are necessary to efficiently feed an ever-growing global population while providing consumers with more choice, including healthy options (Nestle 2013). The industry stands accused by public health advocates of ‘manufacturing epidemics’ through the health harms created by the consumption of ‘ultra-processed’ foods with high levels of sugar, salt, and oil (Stuckler et al. 2012). Global health efforts to strengthen food regulation suggest that, like the tobacco and alcohol industries, Big Food now wields a high degree of influence over public health policy. The regulatory responses to date have placed the onus on national and subnational authorities, with emphasis largely placed on ‘demand-side’ measures aimed at influencing the dietary choices of individual consumers (e.g., labelling, marketing restrictions, health education, taxation of unhealthy foods). Regulation through ‘supply-side’ measures, intended to shape food production, have been adopted to a far lesser degree and to a large extent rely on voluntary compliance by the food industry (e.g., product reformulation, discontinuation of ultra-processed foods) (Alexander, Yach, and Mensah 2011). In countries worldwide, the food industry has resisted stronger and binding regulation by, for example, actively lobbying policymakers, adopting industry codes of practise, and supporting research and policy initiatives that frame the problem as one of poor consumer choice and behaviour (Wiist 2010). The political influence of these efforts is suggested not only by the limited, and relatively weak, food regulations adopted in most national contexts, but also by the limited development of global-level regulatory efforts. In 2011 the UN High Level Meeting on Non-communicable Diseases issued the Political Declaration on the Prevention and Control of NCDs (Resolution A/RES/66/2). This was followed by the adoption of the WHO Global Action Plan for the Prevention and Control of Non-communicable Diseases (2013–-2020). Despite the global restructuring of the food industry and the challenges of regulating transnational food companies at the national level, the plan places ‘the primary role and responsibility on Governments’ to adopt measures ‘as appropriate to national context’, which ‘may include taxes and subsidies, to improve access to healthy dietary choices and create incentives for behaviours associated with improved health outcomes and discourage the consumption of less healthy options’.

Contributions to the Public Interest The business sector has expanded its participation in a range of global health activities since the 1990s as contributions to the public interest. These activities may have been largely prompted by reputational concerns, legal liability risks, and opportunities to grow new markets, but they may also have served a political role, fending off stronger

394   Kelley Lee and Julia Smith regulation while enhancing the legitimacy of the business sector as a participant in global health governance. The strategic engagement by corporations in activities related to the public interest has been especially important for the tobacco industry. By the late 1990s revelations through whistleblowers, litigation, and the public disclosure of internal documents made tobacco companies amongst the least trusted and most negatively perceived by the public (Chaiton, Ferrence, and LeGresley 2006; Moodie et al. 2016). Along with documented evidence of, for example, industry knowledge of the health harms caused by its products, manipulation of nicotine to maximise addiction, and targeting of children and other vulnerable populations, industry strategies to undermine research and policy on tobacco and health were also revealed. By the 1990s, in a context of deep public concern over its activities (Action on Smoking and Health 2001), the tobacco industry attempted to regain public trust. Alongside efforts to donate to public causes such as HIV/AIDS (Smith, Thompson and Lee 2016) and the environment, tobacco companies initiated efforts to designeduced-harm products. The industry had introduced cigarette filters in the 1960s and ‘light’ and low-tar cigarettes in the 1960s and 1970s to allay health concerns. All have subsequently been shown to have no impact on reducing health risks. During the 1980s and 1990s TTCs invested in research and development on a ‘safer cigarette’ but then abruptly cancelled these efforts for fear of increasing the risk of legal liability for their existing products (Moodie 2013). Since the late 2000s ‘harm reduction’ has been the focus of the tobacco industry’s investment in electronic nicotine delivery systems (ENDS), led by electronic cigarettes and heat-not-burn products. These ‘next generation’ devices have since become central to the political repositioning of TTCs. In 2017 Philip Morris International (PMI) announced its manifesto for ‘designing a smoke-free future’ of ‘less harmful’ products because ‘[s]ociety expects us to act responsibly’ (PMI 2017). This was followed by the launch of the Foundation for a Smoke-free World, headed by former director of the WHO Tobacco Free Initiative (TFI) Derek Yach (2017: 1809), who wrote: ‘Philip Morris International has committed to making cigarettes obsolete and is working to internally shift resource allocations and external engagements towards this goal. Independent, unbiased research on the harm reduction potential of alternatives to cigarettes can both inform their activities towards this goal and provide data relevant to regulators’. Similarly, British American Tobacco (BAT) stated: ‘It’s simple; we want to reduce the public health impact of our products’ (BAT 2017). As well as potentially repairing public reputations, ENDS serves an important political strategy by enabling TTCs to reassert policy influence. As stipulated under the FCTC article 5.3, signatory states must take measures to prevent tobacco industry interference in health policy. Buying up and then working through ENDS manufacturers, tobacco companies may circumvent such restrictions. For example, the UK Vaping Industry Association (n.d.) describes itself as established ‘in the political arena, with the public health community and with the media, as part of our mission to build stakeholder-wide confidence in the products we manufacture, supply and retail, so that we can convince every smoker that switching to a vape could positively change their life’. The London E-Cigarette Summit, held annually since 2014, is described as ‘a neutral environment for scientists, policy makers, medical and

Business Sector in Global Health Politics   395 public health professionals, and e-cigarette stakeholders to come together and look critically at the latest scientific research and evidence available on e-cigarettes and then debate their impact in the context of public health and regulation’ (E-Cigarette Summit 2018). The industry’s role in harm reduction has divided the tobacco control community between those who see political engagement with ENDS manufacturers as essential and those who remain deeply suspicious of industry motives. The global food industry has undertaken similar efforts to address public concerns and reassert political legitimacy through reducing the harm of selected products (van de Velde, van Gunst, and Roodenburg 2016). In 1994 Unilever removed trans fats from its margarines and spreads based on internal company research (Tempels, Verweij, and Blok 2017). In 2005 Nestlé rebranded itself a ‘nutrition, health and wellness company’, committed to reformulating its entire product range. By 2014 the company claimed to have ‘renovated’ 10,812 products across two thousand brands made in eighty-six countries (Kummer 2015). Similarly, PepsiCo’s ‘Performance with Purpose’ motto underpins the stated goal to transform the company ‘to adapt to the changing customer preferences of healthier lifestyles and aims to limit its environmental footprint’ (Anonymous 2017). This industry-led and largely unregulated movement towards healthier food has led to significant diversity in what products are reformulated and how, and to varying (often unproven) claims about specific products. Consumers are left to ‘make healthy choices’, amongst a plethora of products and claims, regarding the quality and quantity of products to consume (Brownell 2012). As in the tobacco industry, these efforts can be understood as part of an important political strategy by food manufacturers to reposition themselves as the solution to, rather than the cause of, nutrition-based health harms and thus legitimate participants in policymaking. This contrasts with arguments by public health advocates that a ‘comprehensive and coordinated approach to improving population nutrition’ is needed that includes enforcing ‘mandatory category-specific nutrient targets for processed foods’ (Heart Foundation 2012). The business sector’s support for harm reduction and other activities related to the public interest have been part of the contemporary resurgence of corporate social responsibility (CSR) initiatives: activities and policies through which the business sector in general voluntarily integrates social and environmental concerns into its operations (Vogel 2006). Reputation management has been a central goal of TNCs, with the most controversial industries most actively seeking to portray themselves as ‘responsible’. Alcohol manufacturers promote ‘responsible drinking’ behaviours while leveraging preferential access to emerging markets (Yoon and Lam 2013). KraftHeinz (2017) states that it is ‘committed to responsible, sustainable practises extending to every facet of our business’. GlaxoSmithKline (2017) identifies ‘23 forward-looking commitments across the four areas of our responsible business approach’ aligned with its values of ‘patient focus, integrity, respect for people and transparency’. Japan Tobacco International (2017) positions itself as a ‘proudly responsible business’, and BAT (2010) presents itself as a ‘responsible company in a controversial industry’. The Exxon Mobil Malaria Initiative is the company’s largest CSR initiative, providing US$110 million to fund bednets, diagnostic kits, and drugs for treatment between 2000 and 2013 (Moses 2014).

396   Kelley Lee and Julia Smith In global health, a key form of CSR has been public-private partnerships (PPPs), defined as ‘a collaborative relationship which transcends national boundaries and brings together at least three parties, amongst them a corporation (and/or industry association) and an intergovernmental organisation, so as to achieve a shared ­health-creating goal on the basis of a mutually agreed division of labour’ (Buse and Walt 2000, 550). Most global health initiatives formed since 2000—including the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund), Global Alliance for Vaccines and Immunization (GAVI), and Global Polio Eradication Programme (PEI)— are PPPs. As WHO director-general Brundtland (2002) stated, ‘In a world filled with complex health problems, WHO cannot solve them alone. Governments cannot solve them alone. Nongovernmental organisations, the private sector and Foundations cannot solve them alone. Only through new and innovative partnerships can we make a difference. Whether we like it or not, we are dependent on partners to bridge the gap and achieve health for all’. The pharmaceutical industry has led engagement in global health PPPs, focused on the central challenge of how to make essential medicines affordably accessible to all who need them (see Moon in this volume). This long-standing problem was recognised by the first WHO Model List of Essential Medicines in 1977, adopted to rationalise national policies and promote health equity (Laing 2003). The list continues to be updated biennially, with 155 countries creating national lists of essential medicines in 2016. While the more rational use of limited health resources in low-income countries would seem uncontroversial, the pharmaceutical industry became concerned that such measures would restrict sales in these growing markets. What medicines were included on or excluded from the list impacted government health budgets. By the 1980s attention had shifted to reviewing intellectual property rights (IPRs) as a barrier to affordable access to patented drugs. In response, the industry lobbied the US government to withhold voluntary contributions to WHO, signalling the beginning of long-standing tensions between the private interests of drug patent holders and the public interest of increasing access to medicines (Brown, Cueto, and Fee 2006). In 1986 the Intellectual Property Committee (IPC) was formed by twelve US-based pharmaceutical companies, to lobby for a comprehensive agreement to protect IPRs during negotiations to create the World Trade Organization (WTO). The IPC concluded that it ‘got 95 percent of what it wanted’ in the resultant Trade-Related Intellectual Property Rights (TRIPS) Agreement (Buse, Mays, and Walt 2012, 163). Civil society organisations, patient advocacy groups, and governments of many LMICs opposed the agreement, arguing for affordable access to drugs such as antiretroviral treatment for HIV and AIDS. It was during this period of political conflict between pharmaceutical companies and public health advocates that PPPs were rapidly formed. The precise number of global health–related PPPs established is unknown, given varying definitions and incomplete data, but they are believed to number in the thousands (Ruckert and Labonte 2014). For the business sector, the political and economic motivations for engaging in CSR activities are to fend off binding regulation, improve corporate reputation, advance new markets, and ultimately generate higher profits (Droppert and Bennett 2015).

Business Sector in Global Health Politics   397 For governments, major donor agencies, and international organisations, as well as addressing financial constraints, the business sector can bring much-needed scientific knowledge, technical skill, and operational experience that enable innovation, product development, production, and distribution. A good example is Project Last Mile, a PPP that applies the expertise of the Coca-Cola Company in supply chain management and cold chain storage to improve access to essential vaccines and other medicines in  African countries (Perez and Wollaert 2013). According to the Global Health Technologies Coalition (GHTC), supported by the Gates Foundation and more than twenty-five nonprofit organisations to advocate for new drugs, vaccines, and diagnostics, PPPs are now the key platform for fulfilling this mandate (GHTC n.d.). Thus, CSR has been part of the ‘golden era’ of rising global health funding, which saw a threefold rise in development assistance for health in the early twenty-first century. With stagnating contributions from public sources, partnerships with the business sector have been seen as even more welcome (Mairal 2013). This includes the increased channelling of public sector funding through PPPs. For example, USAID increased its investment in PPPs by almost 40 percent from 2012 to 2013, leveraging more than US$380 million from private sector sources (Miley 2014). From dialogues conducted on PPPs in 2013 by PATH, an international non-governmental organisation (NGO) focused on global health innovations, concluded that ‘[d]onors and partners must provide adequate flex­ ible funding for PPPs to maximise global health impact . . . [s]ustained or increased investment by both public and private sectors will be critical in ensuring the innovation needed to achieve global health equity’ (PATH 2014). As Ruckert and Labonte (2014) conclude, ‘global health partnerships have become ubiquitous within global health governance’. The now accepted, and even expected, contributions by the business sector to furthering the public interest raise important considerations for global health politics. One has been whether public interests truly benefit. Aside from questions about the true value of in-kind donations from pharmaceutical companies, for example, which make up some of the largest (in terms of dollar value) private donations, a large amount of global health spending is to purchase medicines and commodities from private ­companies. For example, the majority of spending by the GAVI Alliance, Clinton Foundation, Affordable Medicines Facility for Malaria, and UNITAID is on commodities from the private sector. These donations have been described as tax efficient ways that companies spend money on their own products in the name of global health (McCoy, Chand, and Sridhar 2009). A second concern is that while partnerships imply shared responsibility and risk, in practise the balance for many PPPs lies more heavily on governments. The business sector, for its limited investment, gains much in enhanced reputation, insider knowledge, and policy influence (Kohler et al. 2016). These concerns are illustrated by a United Nations Population Fund (UNFPA) private sector initiative to increase access to reproductive health commodities through partnerships between governments and contraceptive manufacturers. Governments developed preferential tax and duty conditions, eased manufacturing and import regulations, and supported market research. In return,

398   Kelley Lee and Julia Smith contraceptive manufacturers sold their products at affordable prices, handled distribution, and implemented market-building activities. Under this partnership, governments bore the risk of lost tax revenue and regulatory power, as well as the costs of market research, while the companies were able to influence which countries participated in and benefitted from improved market access (Ollila 2005). Critics argued that rather than relying on the voluntary contributions of the business sector to contribute to public interest needs, governments should address large-scale tax avoidance, tax evasion, and transfer pricing by large corporations and ultra-wealthy individuals (UNRISD 2004; Tørsløv, Weir, and Zucman 2017). Revelations from leaked documents, such as the so-called Panama and Paradise papers, have added new evidence of the scale of such practises and their impacts on public sector financing (Jones 2017). However, it has been the increased capacity of the business sector to influence policymaking, arising from its contributions to public interest needs, that raises the most fundamental concerns in relation to global health politics. Public health advocates have expressed long-standing concerns about industry lobbying of policymakers as external stakeholders, or more indirectly through third parties such as think tanks and industry-funded front groups. CSR and related initiatives provide the business sector with an inside channel for exerting far deeper influence, providing access not only to policymakers, but also to policymaking processes themselves (Hirschhorn 2004; Banerjee 2008). As Hanlon (2009, 157) writes, CSR ‘represents a further embedding of capitalist social relations and a deeper opening up of social life to the dictates of the marketplace’.

Participation in Global Health Governance Participation by the business sector in the governance role of international organisations has arguably been the most significant shift in global health politics since the late twentieth century. In addition to being ‘rule-takers’, subject to the authority of national and international regulatory bodies, the business sector may be acting increasingly as ‘rule-makers’ by contributing to formal decision-making processes, as well as influencing decision-making through less formal processes of norm shaping (Suzuki and Moon 2016). The extent to which this is desirable and the implications for global health politics have elicited growing scholarly debate. One important area of regulation is the adoption of international product standards, governed by the International Organization for Standardization (ISO), to protect the health and safety of consumers. In principle, standards setting should be carried out independently of commercial vested interests and be evidence based. However, because standards can create stipulations that incur additional production costs and thus reduce profitability, the business sector may seek to influence standard setting. For example, Bero (2003) documents how TTCs worked through the Cooperation Centre for Scientific Research Relative to Tobacco to influence ISO standards. Industry representatives dominated the ISO committees involved, supplied industry-derived data, inhibited

Business Sector in Global Health Politics   399 participation by other actors, and developed industry-favouring testing methods. Consequently, existing ISO standards use smoking machine (rather than human) tests to measure the tar and nicotine yields of specific cigarette brands, as the international standard underpinning the marketing of low-tar cigarettes. Independent testing subsequently has shown that machine-based results, because of differences between machine and human inhalation, underestimate human exposures and thus health risks (Holden and Lee 2009, 144). The industry’s ability to have machine-based standards adopted by the ISO, in other words, represented a shift from rule-taker to rule-maker. While formal (legally binding) rules governing global health remain limited, how the business sector has increasingly engaged in rule-making bodies that intersect with the broad determinants of health has received growing scholarly attention. Amongst the most important are negotiations for preferential trade and investment agreements. The proliferation of such agreements, amid stalled progress at WTO Ministerial Meetings (Doha Trade Round) since the early 2000s, has increased opportunities for the business sector to engage with negotiators, gain privileged access to draft texts, and even participate in formal negotiations as members of trade delegations. By contrast, public interest groups are rarely permitted to attend, let alone participate in, such negotiations (Friel et al. 2013; Simmons 2014). This capacity of the business sector to wield influence over rule-making has become even more important as the world trading system has evolved, from a focus on market liberalisation to the agreement of regulatory frameworks that structure international trade (Woll and Artigas 2007). Appau et al. (2017), for example, describe how terms of regional trade agreements have encouraged the consolidation of cigarette production, which in turn has shaped trading patterns of tobacco leaf and the affordability of tobacco products in sub-Saharan Africa. Another key provision under trade and investment negotiations, including draft texts of the Trans-Pacific Partnership (TPP), Canada-EU Comprehensive Economic and Trade Agreement, and bilateral investment agreements, is investor-state dispute settlement (ISDS). Under existing and draft agreements, investors (corporate actors) are permitted to bring cases against governments that adopt standards or policies deemed to adversely impact investments. This includes public policies to protect health and the environment. The potential for the business sector to overturn measures that protect the public interest is illustrated by action taken by the tobacco industry against plain packaging. TTCs have launched multiple ISDS cases worldwide on the grounds that the measures harm their investments (Gleeson and Friel 2013). Even if unsuccessful, the cost of fighting such actions can have a ‘chilling effect’ on governments seeking to adopt public interest policies (Hawkins and Holden 2016). Alongside formal rules, such as international standards and trade agreements, the business sector has sought to influence global health politics by shaping the ideas, values, and norms upon which regulatory frameworks are based. As described previously, industry-supported frameworks tend to limit regulatory strength, scope, and authority. From the growing literature on the ideational power of the business sector in global health, there is evidence suggesting that this has been achieved through industry initiatives to frame public discourse in a variety of ways: generating and disseminating information

400   Kelley Lee and Julia Smith promoting industry-favouring values and world views; organising or sponsoring public events; and working through third parties (sometimes covertly) such as think tanks, paid consultants, industry-supported advocacy groups, and prominent public figures. For example, the Better Regulation initiative in the European Union has been widely promoted amongst policymakers and officials by major corporations, which claim that over regulation of industry is hindering economic prosperity. As Dow Chemical (2017) states: ‘The number of EU health, safety and environment related regulations directly applicable to the EU chemicals industry, has nearly doubled in the last ten years to more than 1,700 legal acts in place today. Current studies conducted for the European Commission suggest that there is a significant cumulative cost to industry, and a ­negative impact on international competitiveness’. Subsequently, Better Regulation principles have come to be promoted by the European Commission (2016) itself as a means of reducing ‘meddling in the lives of citizens or businesses with too many and too detailed rules’. However, as Berry and Devlin (2015: 8) argue, ‘This agenda and the institutions used to deliver ‘better regulation’ are portrayed to the public as part of a positive process of liberation from unnecessary and frustrating red tape, disguising the fact that they weaken and prevent effective laws for the protection of society and the environment’. In other words, norms are created and fostered by powerful corporate interests that depict regulation as necessarily intrusive, over-reaching, and invariably to be reduced, all the while serving certain business sector interests under the guise of public interest. More fundamentally, the extent to which certain ideas, values, and norms have come to shape global health governance lies at the heart of Gill and Benatar’s critique of the Lancet–University of Oslo Commission Report on Global Governance for Health. They write that the ‘analysis and suggested reforms to prevailing institutions and practises are confined within the perspective of the dominant—although unsustainable and inequitable—market-oriented, neoliberal development model of global capitalism’ (Gill and Benatar 2016: 346). As well as reducing the strength and scope of regulation, many parts of the business sector have supported the adoption of non-binding regulatory frameworks in global health, to be adopted and implemented voluntarily by corporate actors. Voluntary standards can enhance company reputation and even guard against legal liability (Fulponi 2006), while retaining discretionary power over what standards to adopt or reject (Ollila 2005). For example, many transnational food companies have pledged to curtail marketing targeted at children and improve food labelling, but the specific commitments made have been set by the companies themselves. Moreover, these pledges have come amid growing calls for stronger and binding government regulation (Sharma, Teret, and Brownell 2010). The extent to which non-binding regulatory frameworks have led to fundamental changes in corporate behaviour, which in turn may lead to improved global health outcomes, has received limited study to date. The capacities of the business sector to exert both material and ideational power, increasingly as participants in global health governance, requires far greater critical scrutiny.

Business Sector in Global Health Politics   401

What Should Be the Role of the Business Sector in Global Health Politics? As described in this chapter, the business sector has become increasingly prominent in global health politics since the 1990s, as subjects of regulation, contributors to the public interest, and participants in global health governance. The previous separation of public and private actors, whether in principle or practise, no longer holds in relation to a broad range of global health issues. As major producers and consumers of goods and services impacting global health, the material influence of the business sector has long been recognised. The need for substantially more financial and other resources, to fill gaps between available resources and agreed global health goals, opened the way for public-private partnerships to proliferate. Between 1999 and 2005 development assistance for health increased from US$6 billion to US$13.4 billion annually, primarily channelled through global health initiatives such as GAVI and the Global Fund (Banati and Moatti 2008). A significant proportion of these resources came from the private sector, to support ‘a wide range of initiatives across the global health value chain, from research and development to manufacturing and supply, and to direct delivery of products and services in various areas of the developing world’ (Dugay 2013). Nor have the commitment levels by the business sector to global health diminished over time, even amid flagging government contributions since the global financial crisis of 2007–2008. During the Global Fund’s Fifth Replenishment Conference in 2016, for example, pledges from private donors and innovative financing initiatives reached US$ 250 million in 2017–2019, more than twice what was pledged in the previous period (GBC Health 2016). For many global health initiatives, therefore, the business sector is acknowledged as filling critical resource gaps and, arguably, enabling initiatives that would never have happened otherwise. Analysing the greater extent of engagement by the business sector and what this tells us about its substantial power and influence in global health politics has been the central purpose of this chapter. This level and scope of engagement, in turn, raises the key question of what the role of the business sector in global health politics should be. It is a question that has elicited much scholarly and policy debate, centring on three main issues. First, for those who accept business sector engagement, the business sector arguably has the right to choose what goals, initiatives, or types of activities to support. In this sense, global health development has become market driven, to an extent that, like consumers, public and private sector donors ‘vote’ through their individual allocation of resources. The capacity to do so, through choices made regarding financial donations, endows the business sector with increased de facto political power and influence. However, others argue that public interests and need should define the global health agenda and priorities. The appropriate funding of global health needs through the collection of taxes

402   Kelley Lee and Julia Smith from major corporations (many of which reportedly pay little or no taxes), and then its allocation by governments for the public good, is favoured over private sector control over donations. The aggregation of donor decisions has been shown to skew the global health agenda towards certain needs, to the neglect of others (McCoy, Chand, and Sridhar 2009). Data on financing for global health have improved significantly since the 1990s, enabling analyses of funding by source, channel, and health focus area. Corporate (US$690 million) and other private (US$3.1 billion) donations for global health represented around 10 percent of total financing for global health in 2016 (Institute for Health Metrics and Evaluation 2016). Alongside more detailed analysis of the specific channels and health focus areas supported by the business sector, there is need for deeper understanding of the political strategies underpinning the business sector’s contributions to global health. Second, as a major contributor to global health initiatives, by extension the business sector has come to be seen by some as a legitimate stakeholder in the governance of these initiatives. While these governance roles have varied in power and influence, the broad shift from rule-taker to rule-maker represents a further blurring of the public and private spheres in global health politics. The desirability of more formalised political authority has elicited strong opinions within the public health community. There remains deep distrust due to efforts by the business sector to prevent or weaken public health standards and regulations. For example, when the Global Business Coalition for Health argued for business interests to participate in the 2011 UN High Level Meeting on the Prevention and Control of Non-communicable Diseases, public health advocates successfully opposed participation by companies such as Coca-Cola (Gonsalves 2011). Revelations of research funding by Coca-Cola to downplay the role of diet in increasing rates of obesity have solidified these concerns (O’Connor 2015). Others challenge the appropriateness of private, for-profit actors asserting decision-making power in public interest issues. Kanavos, Costa-Font, and Seeley (2008), for instance, warn that this may lead to the prioritisation of issue-areas and populations offering greater market opportunities, regulatory frameworks that are market favouring rather than constraining, and modes of operation that support rather than challenge market capitalism (Kanavos et al. 2008). This blurring of political authority held by the public and private sectors has become a central battleground in global health politics. Scholarly analysis of the extent to which this represents needed innovation in forms of global health governance or a ‘privatisation’ or co-option of public authority is greatly needed. The implications for political processes and outcomes in global health require particular scrutiny. Finally, most scholarship to date on the business sector and global health politics has focused on the material forms of corporate power, such as increasingly important donors and occupiers of formal decision-making roles. This is understandable given the acute concentration of global wealth in fewer and fewer pockets. Far less is known, however, about how business interests hold and assert discursive forms of power, which in turn influence the norms, values, and beliefs underpinning global health politics. This chapter has briefly described how many corporate actors have pursued their material interests using strategies aimed at shaping public opinion and scholarly and

Business Sector in Global Health Politics   403 policy debates through, for example, public relations, corporate social responsibility, research funding, recruitment of paid consultants, third parties (e.g., think tanks and front groups), and media coverage. The ‘battle for hearts and minds’ in public policymaking has become global in the early twenty-first century. Public access to the internal documents of some industries has revealed the strategic nature of these activities, the vast resources committed to them, and the capacity to influence political processes at all levels. In the study of global health politics, fuller understanding of the discursive power of the business sector poses a daunting, but most critical, challenge.

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406   Kelley Lee and Julia Smith Kanavos, Panos, Joan Costa-Font, and Elizabeth Seeley. 2008. ‘Competition in Off-Patent Drug Markets: Issues, Regulation and Evidence.’ Economic Policy 23 (55): 499–544. Kean, Yeong Joo. 2014. ‘Breaking the Rules 2014.’ Penang: International Baby Food Action Network and International Code Documentation Centre. http://www.babymilkaction.org /wp-content/uploads/2014/05/BTR14inbrief.pdf. Kenworthy, Nora, Ross MacKenzie, and Kelley Lee, eds. 2016. Case Studies on Corporations and Global Health Governance: Impacts, Influence and Accountability. London: Rowman and Littlefield International. Kohler, Jillian, Martha Martinez, Michael Petkov, and James Sale. 2016. Corruption in the Pharmaceutical Sector: Diagnosing the Challenges. London: Transparency International /UK Aid. http://apps.who.int/medicinedocs/documents/s22500en/s22500en.pdf. KraftHeinz. 2017. ‘Growing a Better World.’ http://www.kraftheinzcompany.com/corporate -social-responsibility.html. Kummer, Corby. 2015. ‘The Nestlé Health Offensive.’ MIT Technology Review, May 26. https:// www.technologyreview.com/s/537611/the-nestl-health-offensive/. Laing, Richard. 2003. ‘25 Years of the WHO Essential Medicines Lists: Progress and Challenges.’ The Lancet 361 (9370): 1723–1729. Lee, Kelley. 2010. ‘Civil Society Organizations and the Functions of Global Health Governance: What Role within Intergovernmental Organizations?’ Global Health Governance 3(2): 1–20. Lee, Kelley, Benjamin Hawkins, and William Wiist. 2016. ‘Researching Corporations and Global Health Governance.’ In Researching Corporations and Global Health Governance: An Interdisciplinary Guide, edited by Kelley Lee and Benjamin Hawkins, 1–14. London: Rowman and Littlefield International. Mairal, Anurag. 2013. ‘Can Collaboration Resuscitate Global Health Funding?’ Guardian, July 31. https://www.theguardian.com/global-development-professionals-network/2013/jul/31 /public-private-partnerships-global-health-programmes. McCambridge, Jim, Kypros Krypi, Colin Drummond, and John Strang. 2014. ‘Alcohol Harm Reduction: Corporate Capture of a Key Concept.’ PLoS Medicine 11 (12): e1001767. McCoy, David, Sudeep Chand, and Devi Sridhar. 2009. ‘Global Health Funding: How Much, Where It Comes from and Where It Goes.’ Health Policy and Planning 24 (6): 407–417. McGoey, Linsey. 2012. ‘Philanthrocapitalism and Its Critics.’ Poetics 40 (2): 185–199. Miley, Marissa. 2014. ‘Public-Private Partnerships: A “Win-Win” for Global Health?’ GlobalPost, July 8. https://www.pri.org/stories/2014-07-08/public-private-partnerships-win -win-global-health. Moodie, Crawford, Leslie Sinclair, Anne Marie Mackintosh, Emily Power, and Linda Bauld. 2016. ‘How Tobacco Companies Are Perceived Within the United Kingdom: An Online Panel.’ Nicotine and Tobacco Research 18 (8): 1766–1772. Moodie, Rob. 2013. ‘Profits and Pandemics: Prevention of Harmful Effects of Tobacco, Alcohol, and Ultra-processed Food and Drink Industries.’ The Lancet 381 (9867): 670–679. Moses, Hamilton, David Matheson, E.  Ray Dorsey, Benjamin George, David Sadoff, and Satoshi Yoshimura. 2013. ‘The Anatomy of Health Care in the United States.’ Journal of the American Medical Association 310 (18): 1947–1963. Moses, Sue-Lynn. 2014. ‘Malaria Is a Top Focus of the ExxonMobil Foundation: Here’s Who It’s Funding.’ Inside Philanthropy, October 23. https://www.insidephilanthropy.com/home /2014/10/23/malaria-is-a-top-focus-of-the-exxonmobil-foundation-heres-wh.html.

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chapter 21

Phil a n thropy a n d Gl oba l H e a lth Jeremy Youde

The World Health Organization (WHO), the intergovernmental organisation with a constitutional mandate to act as the coordinator of global health issues, has a biennial budget of approximately $4 billion. The Bill and Melinda Gates Foundation (BMGF), the world’s wealthiest private philanthropic organisation, provides more than $1 billion for global health programmes annually—including more than $350 million to various WHO activities—on its own. The emergence and growth of private philanthropic organisations like the BMGF have had profound effects on global health governance. Philanthropy brings new resources and new ideas into the global health space, but it also raises questions of accountability and coordination within the global health ­governance system. This chapter aims to explore the role that private philanthropy plays in global health governance. The first section begins by defining philanthropy, then examines the intersection of the study and practise of philanthropy within international relations and its connections to power. The second section addresses the major philanthropic actors and their prominence within global health governance. The next section then describes the advantages that philanthropic organisations proffer, whilst the final section raises questions about the role of philanthropic actors in global health governance.

Philanthropy, International Relations, and Power Payton and Moody define philanthropy as ‘voluntary action for the common good’ (2008, 6). At its core, philanthropy has two key components. The first is financial: philanthropy generally involves some element of financial transfer such as monetary

410   Jeremy Youde donations to groups, causes, or individuals. The second is outcome-based: philanthropy seeks to use those finances to promote the welfare of others or improve the public good (Bremner 1988, 2–3). This does not necessarily mean that philanthropy is wholly selfless; Schuyt explains that philanthropy can be driven by anything from a sense of religious obligation to fear (2013, 5–10). Rather, the idea is that the donor is not the primary beneficiary of the largesse. Furthermore, philanthropy is separate from the state; it comes from individuals, foundations, or corporations. The academic discipline of international relations has typically shied away from investigating the role of philanthropy because of its primary analytical focus on the state. That is particularly unfortunate, as philanthropy has played significant roles in shaping the practise of international relations. Andrew Carnegie donated $1.5 million in 1903 to construct the Peace Palace at The Hague to serve as the headquarters for the Permanent Arbitration Court. Two generations of the Rockefeller family—John D. Jr and Nelson—purchased and donated the land for the headquarters of the United Nations (UN) in New York (Mires 2013, 214–216). More recently Ted Turner pledged $1  billion to the UN Foundation in 1998 (Partzsch and Fuchs 2012, 360–361). These actions have provided both permanence and necessary financing to make international organisations possible. The historical role of private philanthropy is pronounced in global health governance. From 1913 to 1951 the International Health Division (IHD) of the Rockefeller Foundation (RF) was the most important funder of cross-border health concerns. Spending between $18 and $25 million per year for most of its existence, the IHD led campaigns to reduce hookworm and conducted important research on malaria. More important, it provided the financing necessary to support a large portion of the operations of the Health Office of the League of Nations (HOLN). The IHD’s contributions were particularly important because the League itself had few resources available for such support (Youde 2013, 143–147). In fact, the IHD funded approximately half of the HOLN’s annual budgetary outlays (Murphy 1994, 183). Farley argues that ‘before the founding of the WHO in 1948, it [IHD] was arguably the world’s most important agency of public health work’ (2004, 2). Private philanthropy not only made the first generation of international health organisations possible, it also set the stage for today’s global health governance system. When philanthropy and international relations intersect, questions of power are raised. The financial largesse of major philanthropic donors can alter the balance and exercise of power within the international system. Wealth could provide a donor with power over other actors, allowing the donor to force a recipient to do something it would not otherwise do (Dahl 1957, 201); the donor will only give a state money if that government agrees to certain policies. Wealth could also allow a donor to exercise material ­structuralist power if the donor can limit the scope of political and institutional processes that prevent another party from raising issues important to it (Bachrach and Baratz 1962, 948). This same wealth could allow the donor to exercise discursive power by ‘influencing, shaping, or determining [another’s] very wants’ (Lukes 2005, 27). In each of these instances, the concern about philanthropy and global health (or international relations writ large) is that money gives the donor the ability to alter the political

Philanthropy and Global Health   411 agenda to benefit itself over the greater good. Partzsch and Fuchs acknowledge these potential power dimensions but argue that they miss the operating dynamics of philanthropy in international relations. Instead of focusing on how philanthropic actors have power over others, they suggest analysing how they have power with others. In this formulation, neither side can exercise sole power, so the parties must find common ground, develop shared values, and organise together to create collective strength (Partzsch and Fuchs 2012, 360). Whilst both power over and power with dimensions may operate simultaneously, Partzsch and Fuchs argue that disambiguating the dimensions of power allows for a more nuanced understanding of how philanthropic organisations exercise power within the international realm.

Philanthropy and Global Health Today One of the remarkable things about global health aid between 1990 and 2015 is how the range of actors has widened. Initially, global health aid was almost entirely the province of state and governmental actors. In 1990 nearly 90 percent of all development assistance for health (DAH) came through bilateral channels, UN agencies, or regional development banks. Private foundations and non-governmental organisations (NGOs) played only a small, insignificant role (Institute for Health Metrics and Evaluation 2014, 22). Over the next quarter century, as the amount of money dedicated to DAH increased rapidly, more and more types of actors became involved in providing such aid. Private philanthropic organisations have been particularly prominent within this shift. Private foundations and NGOs contribute an increasing percentage of global health aid, contributing at least 20 percent of the world total since 2000. Health is an incredibly popular focus area, with 39 percent of all funding from US-based philanthropies going to health in 2008 (Spero 2010, 10). The Wellcome Trust, based in the United Kingdom, is one of the world’s leading funders of health research, with grants of more than $900  million in 2013 (Viergever and Hendriks 2016, 4). Other leading global health philanthropic donors include the Rockefeller Foundation, the Ford Foundation, the W. K. Kellogg Foundation, the Robert Wood Johnson Foundation, and the Henry J. Kaiser Family Foundation (McCoy et al. 2009a; Stuckler et al. 2011). The most prominent philanthropic actor in global health, however, is the BMGF. With an endowment of $39.6 billion as of December 31, 2015, and having provided $36.7 billion in grants since its inception, the BMGF claims to be (and almost certainly is) the world’s wealthiest philanthropic organisation (Bill and Melinda Gates Foundation 2015). In 2014 alone, the BMGF provided $1.14 billion in grants through its Global Health Program, with additional global-health-related funding for issues like polio eradication, family planning, and vaccine delivery coming through its Global Development Program. The Institute for Health Metrics and Evaluation (IHME)

412   Jeremy Youde estimates the BMGF’s total DAH in 2014 at $1.62 billion, making it the sixth-largest donor for global health that year, surpassing most states (Institute for Health Metrics and Evaluation 2015, 89). Since its inception the BMGF has provided more than $15  billion through its global health programme, making it an increasingly relevant player in global health politics. In addition to the BMGF, other US-based philanthropic organisations contributed an additional $385 million in 2014, slightly more than the global health aid provided by the Australian government in that year (Institute for Health Metrics and Evaluation 2016, 88–89). The BMGF’s involvement in global health began in the 1990s. In 1994 Bill Gates established the William H. Gates Foundation with an endowment of $106 million, run by his father on a volunteer basis. Initially it focused on issues in the Pacific Northwest of the United States. The connection to global health emerged, according to the BMGF, when Bill Gates read an article in the New York Times about the health consequences of the lack of access to clean water in developing countries. Gates was so moved by this article that he passed it along to his father with a note that read, ‘Dad, maybe we can do something about this’ (Bill and Melinda Gates Foundation n.d.). This spurred the William H. Gates Foundation into taking action on global health. In 1999 the Bill and Melinda Gates Foundation came into existence through a merger of three different philanthropies started by Bill Gates during the 1990s. By the end of that year, the BMGF had an endowment of $17.1 billion (Funding Universe n.d.), and global health was one of its core funding areas. The organisation received a huge financial boost in 2006 when Warren Buffett, then the world’s wealthiest person, announced that he would give the BMGF ten million Class B shares of Berkshire Hathaway spread out over a number of years. With the estimated value of the shares at $30 billion, Buffett’s donation doubled the endowment of what was already the world’s wealthiest philanthropy. In addition, Buffett’s donation included a stipulation that the annual amount the BMGF received through his donations had to be used to increase the organisation’s annual grant making and not simply sit in the bank (Loomis 2006). With the BMGF receiving between $1.25 billion and $2.15 billion from Buffett annually, this meant that the organisation has expanded its philanthropic activity in global health tremendously. The BMGF portrays itself as a partner for governments, providing resources and funds that governments cannot. Gates notes that the global economic recession has placed greater strain on national budgets, making it more difficult for traditional donor states to maintain their foreign aid budgets. Into this gap, he notes, foundations like his can enter (Gates 2010, 15–17). Chen notes, however, that the BMGF places restrictions on what types of global health activities it will fund. In particular, it takes a biomedical approach and focuses its funds on research and development of treatment for infectious diseases. It offers little support for healthcare infrastructure, since it sees that as a ­primary responsibility of government (Chen 2006, 663). Through its prodigious spending, the BMGF has had an important effect on the global health agenda in three key ways. First, its willingness to devote significant resources to global health issues has called attention to serious health challenges. Devoting substantial money to an issue grabs international attention and helps shape

Philanthropy and Global Health   413 the global debate. Second, by providing funds for research into and treatment of ­neglected diseases, it has called greater attention to diseases other than HIV/AIDS, tuberculosis, and malaria. Whilst HIV/AIDS, tuberculosis, and malaria remain ­significantly underfunded, their relative prominence on the global health agenda has drowned out attention to other diseases that are less prominent but cause greater morbidity and mortality (Shiffman 2008, 95–100). The BMGF possesses such largesse that it can direct attention towards some of these other issues. Finally, its emphasis on developing new pharmaceutical treatments and using new technologies has elevated the biomedical paradigm within global health. This does not mean that there is no attention paid to the social factors that give rise to global health issues today, but the BMGF’s wealth and emphases allow research on new drugs and vaccines to gain greater prominence within debates. New actors, however, may now be emerging onto the scene. The Chan Zuckerberg Initiative was begun in December 2015 by Mark Zuckerberg (the founder of Facebook) and Priscilla Chan (a paediatrician) with an initial pledge to give or sell up to $1 billion in Facebook shares for each of the next three years. Ultimately the couple announced that they intend to give away 99 percent of their Facebook shares over their lifetimes to advance the initiative (Abutaleb 2015). Based on the value of Facebook stock at the time of the foundation’s announcement, Chan and Zuckerberg will put more than $40 billion towards their foundation (Maloney 2015). Whilst it is too early to know their funding priorities, Chan and Zuckerberg mentioned health as one possible area. In 2014 the couple donated $25 million to the US Centers for Disease Control and Prevention to combat Ebola in West Africa (Kroll 2014). If the Chan Zuckerberg Initiative does direct some portion of its funding towards global health, the IHME suggests that its contributions could help further alter the global health funding landscape (Institute for Health Metrics and Evaluation 2016, 19). Interestingly, Chan and Zuckerberg have decided to structure their new initiative as a limited liability corporation rather than a tax-exempt foundation. This means that the couple will not receive the tax benefits that would accompany donating their shares to a foundation, but they argue that it will give them greater ‘flexibility to execute our mission more effectively’ (cited in Cassidy 2015). Philanthropy in global health also comes from individual purchasing decisions that people make. There is a long legacy of businesses selling special tie-in products for a particular cause, with a portion of the proceeds being directed to relevant organisations. For example, many companies have made ‘pink’ versions of their products to raise funds for breast cancer research (King 2008). In global health, one of the most prominent examples of this sort of consumer-driven philanthropy is (RED), is a licenced branding ethical consumerism campaign amongst a number of leading consumer brands, such as Apple, Converse, Nike, Gap, and Beats by Dre. Each company makes a specially licenced version of one of its products. The company then pledges 50 percent of the profits from those sales to the purchase of antiretroviral drugs in sub-Saharan Africa. Founded in 2006, (RED) claims to have raised more than $350 million, which it has provided to the Global Fund to Fight AIDS, Tuberculosis and Malaria to support grants that have provided seventy million people with treatment, prevention services, and counselling.

414   Jeremy Youde In 2014 it provided $63.6 million to the Global Fund, with an additional $24 million in 2015 and $12.3 million as part of an overall $100 million pledge—the same amount pledged by the Italian government. That makes (RED) the third-largest private contributor to the Global Fund, behind the BMGF and Takeda Pharmaceuticals (Global Fund 2016). Since 2012 (RED) has been a division of the One Campaign, a non-profit organisation co-founded by Bono of the band U2 and focused on eliminating extreme poverty and disease in Africa ([RED] n.d.). (RED) itself takes no profit from any of the products sold under its branding. (RED) very deliberately connects itself to a consumer mentality. According to Bono, his inspiration for the campaign came from talking with Robert Rubin, the former US secretary of the treasury, about the lack of attention paid to HIV/AIDS in Africa. Rubin reportedly told the singer, ‘You need to market this like Nike’ (cited in Stecklow 2006). Because (RED) products are not sold at a premium, the idea is that consumers can make an easy choice with their dollars and get the added bonus of knowing that a portion of the money they spend will support HIV/AIDS programmes in Africa. Whilst it is not the same as participating in a large street march, such consumer-based activism can ‘offer people an inroad—venue—into policymaking that may otherwise be rather closed to grassroots citizen participation’ (Micheletti 2003, 12). To some degree, (RED) is another manifestation of ‘celebrity diplomacy’, wherein celebrities use their fame to bring attention to particular issues on an international scale. Bono, Matt Damon, and Angelina Jolie, for example, have each sought to increase public awareness of various health issues, such as HIV/AIDS, access to clean water, and support for Doctors Without Borders. Cooper (2007, 113) argues that as opposed to official diplomats, celebrities have a connection to domestic society that facilitates increased awareness of key issues, but there are questions about whether celebrity diplomats oversimplify complex problems and recommend inappropriate solutions (Dieter and Kumar 2008).

Advantages of Philanthropy in Global Health Advocates for engaging philanthropic organisations in global health point to three important contributions that such funding sources can make to the international ­system. First, philanthropic foundations increase the diversity of funding sources available for global health issues. This can help to fill gaps that governments are unable or unwilling to address. Weisbrod (1975) explains that non-profit organisations and the voluntary sector, including philanthropic foundations, emerge to satisfy an unfulfilled demand for a public good. In this case, governments and international organisations are unable or unwilling to provide sufficient funding to address global health needs. Philanthropic foundations can thus satisfy a need through a paradigm of partnership and an informal division of labour between governmental and non-governmental sources to supplement, rather than replace, the state (Salmon 1989, 42–44).

Philanthropy and Global Health   415 When the Rockefeller Foundation started investing in international health programmes, there was little funding for cross-border health concerns. A few international health organisations did exist, but they had small budgets and little operational capacity. For the most part, the international community only engaged with international health if a disease threatened to interrupt international commerce (Harrison 2012, 206). When the IHD started its operations, it opened the possibility for international health cooperation and showed governments the value in funding such ventures. The IHD provided the resources that made possible the basics of international epidemiology: conducting fieldwork, training medical personnel, and building laboratory facilities. It also took the lead in research on and development of vaccines for infectious diseases like malaria and yellow fever. Similarly, the BMGF has provided significant resources for scientific research on global health issues and partnered with national governments, intergovernmental organisations, and NGOs on global health campaigns like polio eradication. The BMGF’s efforts have not displaced national governments, but have brought additional resources to bear on particular issues. Prior to the creation of (RED), very little private sector money flowed to the Global Fund. Private corporations ­provided less than $2 million between 2001 and 2006, and none of that money came from US-based corporations (Stecklow 2006) (RED) spurred corporations into action in a way that appealed to their business interests, and it gave consumers the opportunity to use their purchases to support the Global Fund. Whilst there was nothing preventing individuals from donating to the Global Fund on their own, the fact remains that they were not choosing that path. Second, private philanthropic actors can direct attention to neglected parts of the ­global health agenda. Bill Gates noted in 2003: ‘Every year, $70 billion is spent on medical research and development, yet only 10 percent is devoted to diseases that cause 90 percent of the global health burden’. As further evidence of this disjuncture within global health, he pointed out that the US Food and Drug Administration had approved roughly fifteen hundred new drugs between 1978 and 2003, but fewer than twenty of those drugs addressed diseases that primarily afflict developing countries (Gates 2003). These health concerns receive less attention because they lack a direct effect on donor states. From a commercial perspective, pharmaceutical companies have little incentive to invest in researching and developing new drugs and vaccines for countries in the ­global South because they see little commercial potential for them; they prefer to invest in drugs for people who can afford to purchase them (Matter and Keller 2008, 347–348). The rates of yellow fever infection are increasing in Angola, for example, but there is ­little commercial incentive for a for-profit pharmaceutical company to improve upon the existing vaccine developed in 1936 if Angolans cannot afford it (Belluz 2016). Philanthropic organisations can help fill this gap. They do not face the same commercial imperatives of a for-profit pharmaceutical manufacturer, giving them greater freedom to explore areas that may be less profitable. Danzon argues that developing drugs for diseases that primarily afflict low-income countries (LICs) necessarily requires a combination of subsidisation and differential pricing. Private philanthropic organisations, like the BMGF, are uniquely positioned to contribute to these efforts because they can subsidise drug development and foster partnerships with both government and

416   Jeremy Youde industry (Danzon 2007). In this way, not only can a philanthropic organisation like the BMGF itself directly contribute to the betterment of global health, but it can also use its resources to encourage others to become involved. Indeed, Matthews and Ho cite the BMGF’s high-profile health activities as raising awareness of international health within the US government and encouraging the federal government to devote more resources to these issues (Matthews and Ho 2008, 411–412). The IHD focused its health interventions and programmes specifically on areas that did not receive attention from governments or that governments could not address on their own. Few governments in malarial areas in the early twentieth century had the resources to effectively combat the disease or undertake the massive operations necessary to eliminate mosquito breeding grounds. The yellow fever vaccine mentioned above was developed because of investment from the IHD. Whilst (RED) does not fund scientific research, its funding has allowed the Global Fund to provide grants to increase access to antiretroviral drugs in sub-Saharan Africa. It has also arguably increased public awareness about differential access to antiretroviral drugs, which may encourage individuals to pressure their governments into taking action on this front. The average consumer may not pay much attention to HIV/AIDS in Africa, but (RED) offers an avenue through which an individual’s awareness of the issue can be increased. Third, private philanthropic actors can spur innovation and offer unique tools for encouraging new approaches to advancing the global health agenda. Adding philanthropic actors to the global health governance mix allows for greater diversity in strategies and approaches employed in order to address pressing concerns. Philanthropy can provide the necessary risk capital to support new ventures and strategies (Moran 2011, 125). Employing this sort of philanthrocapitalism to global health aims to combine the business acumen of the private sector with the public mobilisation necessary to achieve large-scale social change (McCoy and McGoey 2011, 146). The BMGF explicitly describes its approach to global health as embracing a certain entrepreneurial logic. It uses programmes like the Grand Challenges in Global Health to spur innovation. This programme has identified fifteen specific challenges in seven different goal areas—such as developing a genetic strategy to deplete or incapacitate disease-transmitting insect populations or developing needle-free vaccination ­systems—and provides a financial incentive to become involved in addressing serious gaps in the global health research agenda (Varmus et al. 2003). Governments could initiate this sort of action on their own, but philanthropic actors have demonstrated a greater willingness to use these sorts of innovative techniques to increase involvement in global health issues. The IHD’s innovation came from its willingness to engage in international health work in a variety of countries. At a time when few governments saw much reason to involve themselves in international health, the IHD demonstrated that cooperation on international health was both feasible and mutually beneficial. (RED) has sought to harness existing behaviours and mould them for public good. Rather than trying to get consumers to change their actions, (RED) tries to take advantage of those actions. If a person is going to buy a pair of high-end headphones, why not encourage

Philanthropy and Global Health   417 him or her to buy a pair that will also help finance AIDS drugs in Africa? That action, (RED) argues, may be easier than getting a person simply to donate to the Global Fund.

Criticisms of Philanthropy’s Role in Global Health The burgeoning role of philanthropy in global health has attracted significant criticism. Most of the criticisms fall into four broad categories. First, critics charge that large philanthropic organisations crowd out other voices. Their money gives them an ­outsized and undeserved level of influence and prestige. Cunningim describes the Rockefeller Foundation, which was the world’s wealthiest philanthropy when the IHD was operating, as a ‘centre of immense and perhaps inimical power. . . . It exercises control over many institutions of society, and thus over many individuals. It shapes and moves and works its own will’ (1972, 72). This wealth, according to critics, gave the Rockefeller Foundation the ability to achieve the policy outcomes it desired, which in turn would generate the political and economic conditions that would benefit the Rockefellers’ business interests (Farley 2005, 203–204). By this thinking, the IHD’s health programmes would allow the United States to develop and control markets in poor countries because taming tropical diseases would improve access to natural resources, increase worker productivity, and enrich the Rockefellers’ business interests (Brown 1976, 897). To its critics, the IHD was therefore less an instrument of philanthropy and more a business strategy. These concerns about philanthropic organisations acting as veto players have become even more pronounced in recent years with the emergence of the BMGF and its massive financial resources. Pablo Eisenberg from the Georgetown Public Policy Institute describes the imbalance, ‘You may have foundations with assets larger than almost 70 percent of the world’s nations making decisions about public policy and public priorities without any public discussion or political process’ (cited in Wadman 2007, 248). The priorities of the BMGF and other wealthy philanthropies may not align with those of governments in developing countries. As a result, those priorities get relatively little expression, and the recipient states have few opportunities to voice their concerns or objections. This leads to a situation wherein a philanthropy (like the BMGF) can create a cartel mentality and discourage debate (Bate 2008). Whilst (RED) lacks the financial clout of the BMGF or IHD, its prioritisation of providing antiretroviral drugs in African states may eclipse consideration or funding of other AIDS-related issues that those governments consider more important. (RED)’s exclusive focus on the biomedical side of addressing AIDS in Africa, for example, pays little attention to the underlying social determinants of health, including HIV transmission (O’Manique and Rahman 2013). Financial dependence prevents states from expressing their genuine interests.

418   Jeremy Youde The criticisms of the BMGF’s work on malaria illustrate many of these concerns. In a 2008 memo to senior WHO officials, Arata Kochi, the head of WHO’s malaria ­programme, complained about the BMGF’s overbearing influence. He argued that it was stifling debate about how best to treat and prevent malaria because it only prioritised (and funded) research on new drugs and new technologies. This was particularly problematic, Kochi wrote, because the BMGF funded so many researchers that it was impossible to find independent and impartial reviewers for research proposals that did not hew to the BMGF’s preferred methods. He argued that the foundation was overstepping its bounds by essentially taking over WHO’s policymaking functions. An unnamed ally of Kochi went further, describing BMGF-funded groups as being ‘cowed into stomach-churning groupthink’ (McNeil 2008). Second, critics describe philanthropy as essentially a smokescreen designed to obscure the failures and inequalities inherent within the current international economic system. These philanthropies get their funding from businesses that exploit the liberal economic order to extract wealth. In turn, they reify and justify this system by making it seem benevolent. Donors necessarily have a high degree of power over the recipients. The donors have a sense of agency because they can make choices about who should get money; recipients are at the mercy of donors and may have to alter their plans to satisfy a donor’s interests. Schervish and Ostrander call attention to this power relationship, showing how it actually prioritizes the donor’s interests whilst appearing altruistic (1990, 70–75). As such, philanthropic organisations can use their wealth to maintain the status quo, punish potential challengers, and whitewash the problems in the current economic order. For example, critics argue that upon its creation in 1913, the IHD’s activities ‘were directed more generally at improving the health of each country’s work force to facilitate sufficient economic development to provide the United States with needed raw materials and an adequate market for this country’s manufactured goods’ (Brown 1979, 116). They took this as evidence that Rockefeller’s true interest was enriching himself and using his seeming humanitarian work as a ruse to distract attention or criticism. Other critics allowed that honest altruism played some role in guiding the IHD’s operations, but they argued that this was secondary to its genuine interest in transforming parts of the world to be more economically and politically receptive to US business interests (Löwy and Zylberman 2000, 368). Brown describes the IHD’s programmes as ‘explicitly intended to develop and strengthen institutions that would extend the reach and tighten the grasp of capitalism throughout the society’ (1979, 8–9). In addition to promoting US interests, critics charged that the IHD specifically aimed to prevent the emergence of radical and/ or labour movements that would question the very political and economic systems that gave the Rockefeller Foundation its wealth in the first place. If the IHD could provide health programmes, people would be less inclined to acknowledge the miseries caused by capitalism and thus less interested in joining labour or socialist organisations (Brown 1979, 116–119). Similar charges have dogged the BMGF throughout its existence. Rather than challenging the status quo, critics argue that the BMGF takes the wealth that it

Philanthropy and Global Health   419 a­ ccumulated from an unequal and destructive economic system to paper over the deleterious effects of the liberal capitalist economic order. ‘To overcome widespread disaffection with the new order’s gross inequalities and labour relations, and to strengthen the institutions of capitalism,’ Hindmarsh writes, ‘elite managerial ideals combined with corporate philanthropy’ (2003, 12). The BMGF, its detractors argue, tries to cover up anger about globalisation’s contradictions through philanthropy. It orients its work towards the development of new drugs and new technologies that benefit the current economic order but not the people who most need access to better health systems. Instead of using its power and economic heft to improve global conditions, the BMGF aims to reinforce the dominant order through its philanthropic activity (Moran 2011, 131–133). One factor that critics point to is how the BMGF invests its endowment. It essentially operates in two distinct parts: one side that invests the foundation’s resources in publicly traded companies, and one side that uses the profits from those investments for ­philanthropic activities. These two halves operate independently. Critics charge that the BMGF invests in the very companies that are causing the ill health that the foundation is ostensibly trying to prevent. For example, the BMGF invests in oil companies that operate in Nigeria with appalling environmental, human rights, and health records. It profits from the operations of these companies, but then turns around to provide grants to alleviate environmental health conditions in Nigeria (Piller, Sanders, and Dixon 2007). By providing the investment capital for these oil companies to operate in Nigeria, the foundation incentivizes them to maintain practises harmful to health. Rather than using the power of its wealth to improve the situation, it profits from the harm caused by the liberal economic order. In 2007 The Lancet called on the BMGF to move from passive to active investing, because its wealth would give it the clout to encourage greater change in the international economic system. Third, critics argue that the solutions promoted by philanthropic organisations are more geared to their own interests than to local needs. Rather than accounting for onthe-ground capabilities and interests, the organisations privilege a predetermined set of responses that resonate with their own preferred interests. In particular, the foundations present a technological and biomedical bias that may not actually comport with the recipients’ expressed needs and desires (Moran 2011, 141). With the IHD, some of this criticism focused on its antimalarial programmes, with an emphasis on controlling and eliminating mosquitoes. This led to programmes that prioritised developing new chemicals to kill mosquitoes, draining swamplands, and spraying DDT inside homes. Local doctors frequently sought to challenge this approach, accusing the IHD of overlooking research into new treatments for those suffering from malaria or not considering how its programmes would affect the lived experiences of those communities. The IHD programmes, they argued, fetishised technology and easily quantifiable results over the human element (Stapleton 2004, 207–208). This gave the programmes a veneer of sophistication without actually getting to the heart of the social determinants of health that put populations at risk of contracting malaria in the first place. Given its connection to one of the world’s largest computer companies, the BMGF’s wealth has a direct connection to technology. The responses to health problems that it

420   Jeremy Youde tends to favour exhibit a similar technological bias. Rather than trying to improve access to existing worthwhile technologies, it seeks to create new drugs and technologies (McNeil 2008). As a result, its emphasis promotes approaches that could bring financial remuneration down the road. For example, the BMGF’s own antimalarial programmes promote developing new drugs, new vaccines, and new technologies that may be inappropriate or unworkable in many settings. This has the effect of ‘creat[ing] shortsighted agendas that may miss the most pressing health problems’ (Barth 2010). The foundation’s technological biases mean that it is unable to genuinely address the health concerns that it proclaims it wants to address and improve. Finally, critics allege that few measures of public accountability can exist to provide any sort of oversight of philanthropic organisations. Philanthropists exert significant public policy influence, yet the public itself is largely absent from the conversation. It replaces a mass democratic voice in intergovernmental organisations with a top-down autocratic one that is answerable to no outside or public actor. There is no opportunity for a public dialogue about the priorities and strategies of philanthropic organisations. The Rockefeller Foundation and BMGF both have trustees, but theirs is a fiduciary responsibility to the organisation. The trustees, and by extension the philanthropic organisations that they oversee, are without any sort of broad-based legitimacy due to the lack of any mass deliberative process or public involvement. From its beginning, the IHD (and the Rockefeller Foundation as a whole) came under intense scrutiny about the legitimacy of its operations. The organisation raised suspicions in some quarters that it was ultimately an instrument of American imperialism that operated outside the boundaries of normal democratic control. These concerns nearly prevented the Rockefeller Foundation from beginning operations in the first place. Between 1910 and 1912 John D. Rockefeller repeatedly sought to gain a federal charter from Congress for his philanthropic organisation. On each occasion, Congress rejected his application because of its concerns about his business practises, describing the organisation as holding ‘tainted money’ and symbolic of a ‘creeping capitalism’ that exploited the poor. Since Congress saw Rockefeller’s wealth as ill-gotten and lacked the ability to regulate his business operations at that time, it did not want to give him another unregulated realm in which he could operate. After his repeated failures at the federal level, the Rockefeller Foundation eventually received a charter from New York State in 1913 and began its operations (Cunningim 1972, 20). That did not silence the foundation’s critics, however; they continued to deride the organisation for lacking any accountability to the people it presumably served (Palmer 2009, 681). The BMGF faces similar charges of being both unaccountable and undemocratic. An editorial in The Lancet in 2009 questioned how the BMGF set its priorities, arguing that it lacked an overall global health strategy and was instead driven by the idiosyncratic interests of its founders. ‘For such a large and influential investor in global health, is such a whimsical governance principle good enough?’ it asked (The Lancet 2009, 1577). Others take the BMGF to task for its narrow range of grantees and funding priorities. McCoy et al. (2009b) found that organisations and universities based in the United States received 82 percent of the grant monies that went to nationally based recipients

Philanthropy and Global Health   421 between 1998 and 2007. Of the 659 grants that went to NGOs, only 37 went to organisations based in low- or middle-income countries. The same imbalance exists for grants to universities; only 12 universities not in high-income countries received grants out of the 231 grants made (McCoy et al. 2009b, 1649). This means that the people who have the closest connections to the on-the-ground health priorities in developing countries rarely receive funding. As a result, Black et al. (2009) argue, there is a significant imbalance between the BMGF’s funding priorities and the disease burden in poor states. This allows the BMGF and other philanthropic actors to promote and entrench their particular worldviews in opposition to the needs and desires of those they ostensibly claim to help (Levich 2015). Harman (2017) argues that this speaks to a larger problem with the BMGF: its lack of legitimacy as an actor in the global health realm. Examining the BMGF’s legitimacy is of great importance because the organisation occupies a position of authority due to its wealth, shapes the context of various global health initiatives through its creation and dissemination of relevant knowledge, and uses a personalised basis for claiming authority for its operations and activities. The BMGF, Harman notes, largely bases its authority to act on the basis of charismatic authority and self-legitimation, which is largely abstracted from processes of public deliberation or engagement. By relying on this reified self-legitimation, the BMGF’s activity in global health governance ‘reproduces elite structures of power in global health governance and buys conformity and consent to the rules’ (Harman 2017, 350). More important, ‘To suggest that anything Bill Gates does is legitimate because he is Bill Gates indicates that actors in global health ­governance can be legitimate as long as they are wealthy public figures irrespective of their engagement with the people they work with and upon whom their policies affect’ (Harman 2017, 360). Harman posits that instead of hiding behind its private status, the BMGF—and the wider processes of global health governance—need criticism and public contestation to provide a measure of voice to those who experience the most direct effects of the various global health interventions. Without such a process and the accountability that accompanies it, philanthropy in global health governance threatens to become yet another tool of hegemonic power and domination. The BMGF has a genuine interest in doing good for the world, but there is too little independent oversight ‘to ensure that this desire is translated into the right and most cost-effective set of approaches, strategies, and investments for improving the health of the poor’ (McCoy et al. 2009b, 1652).

Conclusion Reflecting on the literature on global health and philanthropy, three areas should attract greater scrutiny. First, the BMGF receives the overwhelming amount of attention in this area. To some degree, that is a natural outcome of its huge financial resources and influence. That said, the BMGF is not the only player in this space—and its operations are not

422   Jeremy Youde necessarily indicative of global health philanthropy writ large. Focusing so much analysis on one organisation threatens to blind us to the diversity of operations. Second, there are relatively few analyses of how philanthropic organisations interact with intergovernmental organisations engaged in global health governance. Given the potential power that philanthropic actors can wield in global health, it would be useful to understand how and whether public and private actors can collaborate in ongoing, regular, and structured ways. Third, the claims about the disjuncture between donor and recipient priorities would benefit from greater empirical scrutiny and theoretical elaboration. Does philanthropic support for particular programmes free up funding for programmes focused on other diseases? Is this a problem of a lack of consultation between private and public actors? How do we even know a mismatch exists between donor and recipient priorities? There are intuitive reasons to believe that such a disjuncture could exist, but improving the system requires something more concrete than intuition. Philanthropy itself is not new, but the potential effects of philanthropy in the ­contemporary global health governance system have led to questioning about ­philanthropy’s ability to change the international health agenda, the degree of oversight that exists for such organisations, and whether their contribution to global health is ultimately positive. Between their increasing wealth and their growing interest in global health, philanthropic organisations have become increasingly important actors in the global health governance space. Their financial assets give them a unique degree and nature of power within global health, and their structure raises questions about the degree of accountability to the populations they claim to serve. Whilst it would be wrong to entirely dismiss philanthropy as irrelevant to global health, it is worth acknowledging the potential complications that accompany the growth of philanthropy.

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chapter 22

Tr a de a n d I n v estm en t Agr eem en ts a n d the Gl oba l Politics of Hea lth Chris Holden and Benjamin Hawkins

The politics of health are intimately tied to the politics of trade and investment. At the national level, the latter usually revolves around the presumed benefits for populations of greater trade and investment liberalisation (in terms of economic growth), its potential for harming domestic businesses and (by extension) certain workers through increased competition, and the apparent advantages it bestows on large transnational corpor­ ations (TNCs). At the global level, the politics of trade and investment agreements pri­ marily takes the form of bargaining between nation states, but other global actors, most notably TNCs and various civil society organisations, are increasingly making their presence felt. The key actors at both the national and global levels are thus states, corpor­ ations, and civil society organisations and movements. However, these can be further disaggregated in that states, as well as negotiating with one other, have varied internal political institutions that govern how international negotiations are approached and how, once agreed upon, they are ratified. Furthermore, corporations in different indus­ trial sectors, and even within them, have different interests. Civil society organisations and social movements that mobilise around (and often against) trade and investment agreements may also contain diverse sets of actors with very different interests (only some of which are directly concerned with health issues). All of these actors are influ­ enced, in turn, by competing political and economic discourses about the costs and benefits of ‘free’ markets and international trade. Since the 1980s a dominant ‘neoliberal’ discourse has assumed that less-regulated markets are better than more-regulated ones, although the reality of international trade is that it is a managed system, which is the product of interstate bargaining, rather than one with entirely open borders.

428   Chris Holden and Benjamin Hawkins Trade negotiations between states, and conflicts over trade within them, are focused principally on perceptions of relative economic benefits. Yet as the system of inter­ national trade and investment has developed, it has become apparent that these same negotiations and conflicts can also have important implications for health. Health concerns have therefore moved from the margins of such processes to attain greater recognition, so that trade and investment agreements are acknowledged as important (actual or potential) causes of health outcomes for the populations involved. Such con­ cerns have often revolved around the constraints that trade and investment agreements may impose on governments’ ability to make public policy that protects and enhances the health of their citizens. In this chapter we first outline the key processes of the World Trade Organization (WTO), the multilateral organisation that brings together almost all countries on trade issues, provides a forum for them to negotiate trade deals and resolve disputes, and provides the principal legal and normative frameworks governing international trade. We examine an important WTO dispute between Indonesia and the United States concerning flavoured cigarettes, to illustrate the way the WTO system works, the roles of states and corporations within it, and its implications for health politics. We then briefly discuss a number of other key disputes with important implications for health. Following this, we analyse the ‘next generation’ of trade and investment agreements, focusing on two key aspects that are relevant to health: investor-state dispute settlement (ISDS) mechanisms and regulatory cooperation. Finally, we discuss political struggles over these new agreements, demonstrating once again how domestic and global factors interact in the politics of trade and health.

The World Trade Organization and the Global Politics of Health The WTO was established in 1995, following the Uruguay Round of trade negotiations. It is the successor to the multilateral trade system centred on the General Agreement on Tariffs and Trade (GATT), which governed international trade during the post–World War II period. The GATT system, and the WTO system that succeeded it, operates on the basis of periodic ‘rounds’ of trade negotiations by member states, which negotiate with each other to bargain down tariff rates and other trade barriers. The Uruguay Round agreed to create the WTO and added to the GATT a series of new trade agree­ ments, including the General Agreement on Trade in Services (GATS), the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS), the Agreement on the Application of Sanitary and Phytosanitary Measures (the SPS Agreement, concerned with regulations to protect human, animal, and plant life and health), and the Technical Barriers to Trade (TBT) Agreement.

Trade and Investment Agreements   429 WTO agreements, and most other trade agreements, are based on a set of principles aimed at ensuring that agreements to remove or reduce trade barriers are applied in a non-discriminatory manner. The most important of these principles are the ‘most favoured nation’ principle, which stipulates that concessions made to one party are extended to all other parties, and the ‘national treatment’ principle, which holds that foreign goods, services, and intellectual property (depending on the scope of the agree­ ment) must be treated no less favourably than like domestic ones once they have entered the market. When agreeing on the creation of the WTO, the Uruguay Round also created a new dispute settlement system, which replaced the weaker dispute settlement process of the GATT system. Under the new system, if a member state believes that another member state has violated a WTO agreement or commitment, it can initiate a dispute via the Dispute Settlement Body (DSB). If the parties cannot agree, the dispute is then ruled upon by a panel composed of trade experts, with a right of appeal to an Appellate Body. Once a panel’s (or the Appellate Body’s) ruling is adopted by the member states meeting as the DSB, the losing party must comply with the decision, negotiate compensation to the other party, or face retaliation in the form of the suspension of concessions (i.e., the imposition of trade sanctions such as tariffs). The WTO’s agreements, and its dispute settlement process, have become important to health policy because a number of provisions of the agreements may be seen as pla­ cing constraints on the scope that governments have to implement domestic laws and regulations in the pursuit of health objectives. Put differently, the WTO regime may limit governments’ ‘policy space’. Most WTO agreements have provisions that make exceptions for national laws or regulations that, while otherwise violating WTO com­ mitments, are necessary for the protection of human, animal, or plant health. However, such measures are subject to a ‘necessity’ test, according to which they must be as least trade restrictive as possible, and they must be applied in a non-discriminatory manner, based on scientific evidence and international standards, and not a disguised form of protection (WHO/WTO 2002).

Indonesia versus the United States on Cigarette Flavourings We can illustrate the way this system works, and the implications for health politics, by examining actual cases of WTO disputes relevant to health. We discuss here the dispute between Indonesia and the United States over the latter’s ban on flavourings in cigarettes in the Family Smoking Prevention and Tobacco Control Act of 2009 (hereafter ‘the Act’). The Act asserted the Food and Drug Administration’s (FDA) authority to regulate tobacco products, including by setting public health standards for them, such as specify­ ing legal levels of tar or nicotine; introduced limitations on the colour and design of pack­ aging and advertising; and introduced new measures to protect children (Jarman 2015, 62). As part of the latter, the Act banned characterising flavours from cigarettes, including

430   Chris Holden and Benjamin Hawkins candy, fruit, clove, and cinnamon, but exempted menthol. The intent was to protect youth and children from smoking, since it was believed that they are more likely to be attracted to flavoured cigarettes. In June 2010 Indonesia requested the establishment of a WTO dispute panel, arguing that the banning of clove cigarettes was discriminatory, given that menthol cigarettes had been exempted. Indonesia is the world’s fifth largest cigarette market, with the tobacco industry exerting a high level of influence on government policy (Hurt et al. 2012, 306). Clove cigarettes (known as ‘kreteks’) are the main form of tobacco consump­ tion in Indonesia. The country is the largest exporter of such cigarettes to the United States and other countries. While the clove cigarette market is small in the United States, most clove cigarettes are imported, whereas most menthol cigarettes are produced domestically (Jarman 2015, 64). Menthol is the most popular flavoured cigarette in the United States, with a large market amongst African Americans. The Indonesian govern­ ment argued that the differential treatment of clove and menthol cigarettes, which should be regarded as like products, was discriminatory and therefore violated both the GATT and the TBT agreements, and further that the US measure was more trade restrictive than necessary to protect human health (WTO 2014). The WTO dispute panel concluded in September 2011 that the US law violated WTO law by treating like products differently, although it rejected Indonesia’s claim that the US measure was more trade restrictive than necessary. The United States then appealed, and the Appellate Body upheld the panel’s original ruling, although with some minor differences in the interpretation of the relevant agreements (see McGrady and Jones 2013 for a full legal analysis). Given that the banning of clove cigarettes, alongside the con­ tinuing allowance of the sale of menthol cigarettes, constituted discrimination between like products under WTO law, the US government faced the choice of whether to bring its laws into conformity with WTO law, by allowing the sale of clove cigarettes or ban­ ning the sale of menthol cigarettes, or to refuse to do so and face sanctions. The manner in which the dispute was ultimately resolved tells us as much about the global politics of trade and health as it does about the formal legal processes within the WTO. First, the US government had to consider the domestic implications of banning menthol cigarettes. Both scientific and political considerations were relevant. In terms of the scientific evidence on the effects of menthol in masking the harshness of tobacco, the United States argued in the dispute that clove cigarettes were more attractive to young people and therefore posed a greater health risk than menthol cigarettes. However, the panel and the Appellate Body ruled that menthol and clove cigarettes had the same char­ acteristics in terms of their effect on rates of youth smoking (McGrady and Jones 2013). The United States also argued that it was legitimate to exempt menthol cigarettes from the ban because to include them might lead to a large number of citizens experiencing sudden withdrawal from nicotine addiction and a large rise in illicit trade. Both claims were rejected by the Appellate Body, since ordinary cigarettes would still be available (McCabe Centre for Law and Cancer 2014). When first passing the Act, the US government had in fact postponed a decision on whether to ban menthol cigarettes, instead asking the FDA’s Tobacco Products Scientific

Trade and Investment Agreements   431 Advisory Committee (TPSAC) to investigate the issue. The TPSAC reported that ­menthol cigarettes have an adverse impact on public health because they increase the likelihood of experimentation by young people and African Americans; increase the likelihood of addiction and the degree of addiction in youth smokers; and decrease the likelihood of smoking cessation, particularly for African American smokers, and also reported that marketing of menthol cigarettes increases the prevalence of smoking for the whole population, for youths and for African Americans (TPSAC 2011). Especially concerning was ‘the high rate of menthol cigarette smoking amongst youth and the trend over the last decade of increasing menthol cigarette smoking amongst 12–17 year olds, even as smoking of non-menthol cigarettes declines’ (TPSAC 2011, 220). A further report was commissioned from the FDA, which arrived at similar conclusions (FDA 2013), and a consultation on the issue was held in 2013, following the ruling of the WTO’s Appellate Body. However, the banning of menthol cigarettes would have constituted a political problem. Menthol cigarettes comprised at least 20 percent of the overall US cigarette market. Approximately 29 percent of all menthol smokers are African American, and more than 80 percent of African American smokers use menthol cigarettes (Rock et al. 2010, 117–119). As a distinct population of voters, African American smokers represented a potential political obstacle to the banning of menthol cigarettes, with some African American organisations publicly criticising the idea of a ban (Glanton 2010). Other African American organisations saw the exemption of menthol from the ban as a form of dis­ crimination against those African Americans whose health would inevitably be harmed by the continued consumption of menthol cigarettes (Glanton 2010). Some authors highlighted the concerted menthol cigarette marketing campaigns tobacco companies had run over a number of years, specifically targeting African Americans in low-income urban areas (Cruz et al. 2010). The issue was then seen as one of social justice as well as of public health (Gardiner and Clark 2010). Seven former federal health secretaries, from both Democratic and Republican administrations, sent a letter to members of the Senate and the House of Representatives arguing that the exemption of menthol ‘caves to the financial interests of tobacco companies and discriminates against African Americans. . . . It sends a message that African American youngsters are valued less than white youngsters’ (cited in Saul 2008). The tobacco industry constituted a further political obstacle to a menthol ban. The main producer of menthol cigarettes in the United States was Lorillard, which earned approximately 90 percent of its revenues from just one menthol brand, with Philip Morris and R.J. Reynolds (RJR) having smaller shares of the menthol market (Zajac 2011). Large tobacco companies engage extensively in lobbying in the United States and elsewhere (Givel and Glantz 2001; Holden and Lee 2009). Lorillard and RJR had in fact sued the FDA, arguing that key members of TPSAC had conflicts of interest that should have barred them from participating in the report (Zajac 2011). While this legal challenge was ultimately rejected on appeal (Myers 2016), the case indicates an attempt by Lorillard to discredit the findings of TPSAC. Furthermore, there was strong opposition to a ban on menthol from Republicans, who held a majority in the House of Representatives.

432   Chris Holden and Benjamin Hawkins It has been observed that President Barack Obama may have been reluctant to engage in another political battle while embroiled in defending his healthcare reforms and negoti­ ating over the federal deficit (Zajac 2011; Siegel 2011). Furthermore, the tobacco control community was split on the issue of exempting menthol, since this was the result of an uneasy compromise between the industry and some tobacco control advocates (Siegel 2011). Tobacco control advocates supporting this compromise argued that it was a necessary trade-off to ensure the industry conceded the FDA’s authority to regulate tobacco products, which the industry had previously been successful in legally challen­ ging (Jarman 2015, 64). However, the divisions amongst public health advocates on this issue allowed the tobacco industry to dominate the public discourse, claiming that a ban on menthol cigarettes would lead to an increase in illicit trade (Cheyne et al. 2014). A WTO ruling in a case such as this would normally lead to a change in national-level law or relevant regulations to bring them into compliance. In this case, this would have meant the US government either banning menthol cigarettes or allowing the sale of clove cigarettes. However, the evidence in favour of a ban on flavoured cigarettes in gen­ eral, including clove, had already been accepted by the US government when it passed the Act and had also been accepted by the WTO panel and Appellate Body as legitimate (as long as it was undertaken in a non-discriminatory manner). Thus, amending the Act to allow the sale of clove cigarettes was not a satisfactory solution. The domestic political obstacles to US compliance, therefore, led the United States to take measures short of banning menthol, including releasing the FDA’s scientific evaluation of menthol cigar­ ettes, developing a youth education campaign, providing information on the health risks posed by menthol cigarettes through a website, and educating the public through the National Cancer Institute website (McCabe Centre for Law and Cancer 2014). When a complaining member state believes a defending state has not complied with a WTO disputes ruling, the affected state can apply for the right to suspend concessions (i.e., implement sanctions), as Indonesia then did. When the United States objected, the matter was referred to WTO arbitration. However, before an arbitration decision was returned, the two governments announced a memorandum of understanding and the WTO process then ceased. Under the negotiated settlement, the US Act remained in force, but the US government agreed not to impede market access by Indonesian clove cigars and cigarillos, at least until new non-discriminatory measures could be introduced (ICTSD 2014; McCabe Centre for Law and Cancer 2014). This was in the context of Indonesian clove cigarette manufacturers having adapted clove cigarettes into cigars and cigarillos to circumvent the ban. The settlement also involved a number of trade-related matters not directly connected to the clove cigarettes dispute. These included a commitment by the United States that it would not submit a WTO challenge regarding unrelated mineral export restrictions imposed by Indonesia; a commitment by the United States to grant add­ itional ‘facilities’ to Indonesia should Congress reauthorize the Generalized System of Preferences, a trade program to support less-developed countries; and an agreement that the two countries would intensify negotiations to strengthen intellectual property rights in Indonesia (ICTSD 2014; Needham 2014). They also agreed to intensify their

Trade and Investment Agreements   433 cooperation via the Indonesia-US Trade and Investment Framework Agreement (TIFA), a mechanism for regular trade talks between the two countries. The extent to which the final settlement benefits Indonesia is unclear. It appears that the domestic political obstacles to US compliance with the WTO panel and Appellate Body led the government to seek a solution via direct negotiation with Indonesia. This raises important questions about the informal power that states with large economies like the United States have within the WTO system and the actual capacity of low- and middle-income countries (LMICs) to use and benefit from the dispute settlement proc­ess. The WTO operates on the formal basis that member states are equal within its proc­esses, and it was assumed that the move to binding third-party arbitration upon the imple­ mentation of its dispute settlement process in 1995 would favour poorer and smaller states (Smith, 2004). Yet the uneven wealth and power of WTO members means that this may not be the case in practise. LMICs often lack the legal capacity to prepare and carry through disputes to the same extent as high-income countries (HICs), thus affect­ ing decisions about whether to initiate and prosecute disputes (Guzman and Simmons 2005; Busch et al 2008). HICs may also threaten to withdraw other benefits such as aid or trade preferences, putting informal pressure on potential complainants (Smith 2004, 548). Despite the formal legal process of WTO dispute settlement, interstate bargaining takes place throughout it, including before the formal initiation of a dispute; during the dispute process; and following a ruling, when agreement on implementation can avoid the application of formal sanctions (Tallberg and Smith 2014). States with greater mar­ ket size and therefore lower vulnerability to sanctions are more able to resist or delay compliance, even when they have been found in breach of WTO law (Tallberg and Smith 2014). The Indonesian-US dispute thus demonstrates how domestic and international pol­ itics, and the varied actors within each that assert their interests, serve to intertwine the politics of trade and health. In this case, the United States was able to work out an uneasy compromise that allowed it to continue to ban most flavoured cigarettes, which may be regarded as a positive development for the protection of health. Yet menthol cigarettes and clove cigars continue to be sold despite scientific evidence that banning them would advance public health. Furthermore, the final agreement between the United States and Indonesia was reached outside the formal mechanisms of the WTO dispute process, in a manner that suggests that large or high-income countries can circumvent panel rulings in ways that smaller or lower-income countries would not be able to.

Other WTO Disputes and the Global Politics of Health Other WTO disputes involving tobacco control also illustrate the implications of WTO law for the global politics of health. A GATT dispute between the United States and Thailand in 1989 was instrumental in forcing the Thai government to allow trans­ national tobacco companies (TTCs) access to the Thai market (Vateesatokit et al. 2000). More recently, disputes involving tobacco have been increasing within the WTO, in

434   Chris Holden and Benjamin Hawkins many cases with LMICs as the complainants, despite their relative lack of legal capacity. In such cases, these governments may act as surrogates for TTCs, which have been marginalised from the policymaking process in many HICs (Eckhardt et al 2016). A  particularly important example is the WTO disputes initiated by Ukraine (later withdrawn), Honduras, Dominican Republic, Cuba, and Indonesia against Australia’s introduction of plain packaging, claiming intellectual property rights violations, with Philip Morris International (PMI) and British American Tobacco (BAT) paying the legal expenses of some of the complainant countries (Eckhardt et al. 2016). Lobbying and various forms of assistance or inducement may therefore lead to WTO member states acting as proxies for corporate interests, with a shift from HICs to LMICs as the complainants (Eckhardt and De Bievre 2015). WTO agreements also have implications for the politics of other major health issues. For example, the TRIPS Agreement may impact the affordability of medicines in LMICs (Smith et al. 2009). GATS has potentially far-reaching consequences for the delivery of health services, primarily because it raises questions about the extent to which govern­ ments can protect state-provided or -financed services from commercial competition (Holden 2014). While there has not yet been a significant GATS dispute relating to health services, there have been important WTO disputes in other areas relating to health. For example, the United States and Canada initiated a dispute against the European Union (EU) in 1996 to challenge the latter’s imposition of a ban on the import of hormone-treated beef (WTO 2016). While the case is extremely complex, the panel found in favour of the United States and Canada on the basis that there was not sufficient evidence of the harmfulness of the hormones. The dispute is of particular relevance because it casts doubt on the extent to which WTO panels will take account of the ‘pre­ cautionary principle’, which states that in the absence of scientific consensus, the burden of proof that something is not harmful rests with those taking the relevant action (in this case, using certain hormones in the rearing of beef). The WTO agreement dealing most explicitly with food standards, the SPS agreement, allows governments to put in place provisional measures to protect health where scientific evidence is inconclusive, but these must be temporary while further information is sought to clarify the risk (WHO/ WTO 2002, 67–68). In another example, Canada filed a complaint against France in 1998, arguing that France’s imposition of a ban on chrysotile asbestos treated imported asbestos less favourably than domestic asbestos substitutes. In this case, the WTO Appellate Body ruled in France’s favour on the basis that the ban was a legitimate meas­ ure to protect health (WTO 2010; WHO/WTO 2002). It is not only WTO agreements that are significant for health. In recent decades numerous bilateral and regional trade and investment agreements have emerged that have potentially wide-ranging health impacts. A key feature of the WTO system is that it is premised on bargaining between states, which have de jure equivalence, des­ pite their de facto differences in terms of their economic and political power. This interstate bargaining has led to deadlock in the most recent WTO negotiating round, the Doha Round. China’s increased weight in the global economy, and its membership

Trade and Investment Agreements   435 in the WTO since the beginning of the Doha Round in 2001, has allowed it to build an alliance with other ‘BRICS’ countries (Brazil, Russia, India, and South Africa) that has led to stalemate in WTO negotiations with the United States and the EU. This stale­ mate was the spur for the launch by the United States and the EU of negotiations for a new set of trade and investment agreements outside of the mechanisms of the WTO. The next section discusses some of the health implications of these ‘next generation’ agreements.

Conflicts over ‘Next Generation’ Trade and Investment Agreements Given the continued foundering of WTO negotiations, the two most important amongst the new agreements are the Transatlantic Trade and Investment Partnership (TTIP) and the Trans-Pacific Partnership (TPP). TTIP is a proposed agreement between the EU and the United States, whereas TPP includes the United States and eleven countries in the Pacific Rim. At the time of writing, negotiations for TTIP were ongoing, and though the TPP negotiations had been finalised, the agreement had not been ratified prior to the US presidential elections in November 2016. Following the election of Donald Trump, it remained unclear whether either agreement would be successfully concluded and enter into force. A third agreement, the Comprehensive Economic and Trade Agreement (CETA) between the EU and Canada, was signed on October 30, 2016; at the time of writing, it was awaiting ratification by the Canadian government, EU insti­ tutions, and the twenty-eight member states. While it would be possible to provisionally apply CETA pending its ratification, this process may be further complicated by the decision of the United Kingdom to leave the EU and the subsequent negotiations over the terms of exit. Despite the uncertainty surrounding these agreements, they remain important because they illustrate the partial bypassing of the WTO system. They also typify the kind of provisions that the world’s most powerful states have sought to incorporate in parallel structures, which may form the basis of future trade agreements but which have given rise to extensive controversy. Provisions contained within TPP, TTIP, and CETA are noteworthy for the ramifica­ tions they are likely to have for the wider global trading system. These agreements ­signified a substantial, qualitative change in the very nature of international trade agreements. It has been argued that current agreements are not, in fact, trade agreements at all in the traditional sense. Historically, such agreements have dealt principally with trade in goods, rather than services, and with the removal of tariffs and tariff-equivalent meas­ures such as quotas. However, for countries such as the United States and EU member states, much of the heavy lifting has already been completed in these areas by successive advances in the multilateral trading regime. Despite some exceptions, tariffs on the

436   Chris Holden and Benjamin Hawkins trade of manufactured goods between advanced economies have fallen to historically low levels in recent decades. The pursuit of further trade liberalisation amongst these states has therefore shifted its focus to other, more indirect, non-tariff barriers to trade, which are seen as having significant trade-distorting effects. These include measures that are less about trade, in a straightforward sense, and more about transnational investment arrangements and ‘behind the border’ measures affecting national regula­ tory standards. The focus on such measures necessitates even greater engagement with domestic laws and public policies, which may deliberately, or inadvertently, have trade diversionary or discriminatory effects. If concluded, these agreements would create a powerful precedent regarding the type of provisions that should be included in future trade and investment agreements. Two aspects of this shift are particularly important for the politics of health: ISDS and regulatory cooperation. The next two sections dis­ cuss these, prior to a discussion of the political struggles around the adoption of the agreements and the incorporation of these measures within them.

Investor-State Dispute Settlement, Corporate Interests, and Health ISDS mechanisms have existed for some time within bilateral investment treaties (BITs) dating back to the Germany-Pakistan BIT in 1959. The number of BITs expanded hugely during and after the 1990s, with over 2,500 now in existence. However, the principle of ISDS became increasingly controversial following its proposed incorporation within TPP, TTIP, and CETA. ISDS mechanisms seek to reassure transnational investors— predominantly TNCs—that their investments will be safe from arbitrary expropriation, and that they will be subject to ‘fair and equitable treatment’ and thus allow investors to initiate disputes directly with governments where such guarantees appear to have been violated (McGrady 2012). ISDS mechanisms were introduced initially in BITs between high-income and low-income countries, as an antidote to concerns about the effective­ ness of legal systems in LMICs receiving investment and the ability of investors to fully guarantee their property rights within existing legal structures. The proposed inclusion of ISDS provisions within TTIP—an agreement between two advanced capitalist economies with highly developed independent legal systems—has proved particularly controversial. Civil society movements across the relevant countries have mobilised against all three agreements, and subsequent opposition by some leading politicians and major political parties has meant that the passage of the agreements through the rele­ vant parliaments is far from guaranteed, as explained below. ISDS has been particularly controversial because of the direct, and exclusive, rights it gives to corporations to initiate disputes with governments. While in the WTO system corporations can lobby member states to initiate disputes on their behalf, under ISDS mechanisms corporations have legal standing to initiate disputes directly with ‘host’ governments. ISDS mechanisms are also not overseen by a multilateral body such as the

Trade and Investment Agreements   437 WTO, but operate on the basis of a variety of ad hoc panels composed of trade and investment lawyers who, it has been argued, have a material interest in ruling in favour of corporations to ensure a continued flow of cases (Eberhardt and Olivet 2012). The fragmentary nature of this system also means that the outcomes of arbitration processes are often inconsistent and highly unpredictable, with disparate judgements in multiple tribunals precluding the emergence of a unified and coherent body of trade and invest­ ment case law (Van Harten 2007). The important implications of ISDS mechanisms for health are highlighted by the ini­ tiation of two BIT disputes by PMI, against the Australian and Uruguayan governments, contesting their respective regulations on cigarette packaging (Hawkins and Holden 2016). In both the case against Uruguay under the Switzerland-Uruguay BIT and against Australia under the Australia-Hong Kong BIT, PMI argued that by placing extensive limits on the design of cigarette packs, these governments had deprived the company of its intellectual property rights and prevented it from freely using its trademarks. While the panels in both disputes ultimately found in favour of the respective governments, there is evidence that the initiation of these disputes has worked as a disincentive to other governments, particularly in LMICs, to pursue similarly stringent cigarette pack­ aging requirements for fear of incurring similar legal action (Hawkins and Holden 2016). Moreover, the governments in both cases incurred substantial legal costs and devoted significant human resources to defending their policies. These resources were thus diverted from other governmental tasks, including the provision and management of health services. Hawkins and Holden (2016) argue that the fragmentation and complexity that char­ acterise the international trade and investment regime, with a ‘spaghetti bowl’ of WTO, regional, and bilateral agreements overlaying each other, present a multiplicity of chan­ nels through which corporations may challenge laws designed to protect public health, but which work against their business interests. The conclusion of each new agreement that includes ISDS provisions creates an additional potential ‘veto point’ (Hawkins and Holden 2016). This allows TNCs to ‘venue shop’, that is, to seek out and exploit the agreements under which they are most likely to achieve their goals. Corporations may initiate parallel disputes in any of these potential venues, including suits within domes­ tic legal systems, challenges lodged by governments on corporations’ behalf within the WTO system, and direct disputes initiated by TNCs using ISDS mechanisms within bilateral or regional agreements. Precisely such an array of disputes was initiated by TTCs against the Australian government’s plain packaging law. For corporations, the intent is to overturn the targeted law and discourage other governments from adopting similar meas­ures. Such tactics are likely to be particularly effective against LMICs, which have limited capacity to fight such legal disputes on any one, let alone all, of these fronts. In response to the threat of trade litigation by TTCs, Bloomberg Philanthropies and the Bill and Melinda Gates Foundation created an Anti-Tobacco Trade Litigation Fund in March 2015 to support LMICs being sued by tobacco companies (Tobacco Free Kids n.d.).

438   Chris Holden and Benjamin Hawkins

Regulatory Cooperation and Health As discussed in the previous section, ISDS measures introduce a mechanism through which investors can seek ex post remedies to unfair or discriminatory practises that contravene the principles of trade and investment agreements. Both TPP and TTIP, however, proposed moving beyond this to include more robust ex ante mechanisms to ensure national laws remain in accordance with a state’s obligations under the agree­ ment. While TPP includes a chapter on ‘regulatory coherence’, the draft TTIP agreement includes chapters on both regulatory coherence and ‘regulatory cooperation’. The latter is designed as a form of monitoring and oversight of proposed domestic legislation before its adoption. However, since the TTIP agreement remains under negotiation, the precise details of how this would function in practise, the institutional structures that would oversee and administer it, and the degree of access this would afford to private stakeholders such as TNCs remain uncertain. This section focuses principally on TTIP, as the most far-reaching set of proposals in this area, but many of the concerns raised here are pertinent to discussions about the impact of other agreements such as TPP. The process of negotiation at an interregional level for TTIP is analogous to that undertaken within the EU during the completion of the single internal market (SIM) (see Egan 2001). In order to create a genuinely European market, the European Commission sought to harmonise production and safety standards in specific areas to create common benchmarks, which all producers must adhere to regardless of national origin. In other areas, where harmonisation was deemed unnecessary or impractical, the norm of mutual recognition was established, whereby products legally produced and deemed safe to bring to market in any member state must be accepted within other EU states. Like the SIM project, TTIP necessitates the formulation of either common standards (harmonisation), on issues such as food safety and a range of other issues, or mutual recognition of standards between the United States and the EU. Regulatory cooperation mechanisms are designed to ensure that proposed laws do not undermine either regime. If ISDS is a mechanism of redress, in cases in which the fundamental principles of the agreement are seen to have been infringed by government acts, regula­ tory cooperation is designed to avoid such instances occurring in the first place. Critics of TTIP have highlighted the importance of the Regulatory Cooperation Chapter within the agreement on similar grounds to ISDS mechanisms. The establish­ ment of processes and structures that would require draft laws on both sides of the Atlantic to be scrutinised prior to their adoption, and perhaps even to their formal pro­ posal, has clear implications for democratic accountability and legislative sovereignty. It affords corporate actors a potentially powerful mechanism through which to influence policy at the pre-proposal stages of the legislative process. The ability to set agendas and shape legislation at the very earliest juncture has long been identified as a key aspect of the exercise of political power (Bachrach and Baratz 1962). Similarly, scholars of behav­ ioural economics have long understood the importance of initial proposals in ‘anchoring’ subsequent negotiations (Tversky and Kahneman 1974). This has fuelled concerns that,

Trade and Investment Agreements   439 like ISDS, regulatory cooperation may have a ‘chilling effect’ on legislative programs, with governments reluctant to regulate in the public interest in areas such as health and safety, the environment, and social policy, where such regulations may be seen by businesses as imposing burdens. Where governments are prepared to propose new measures, the existence of regulatory cooperation mechanisms may create an additional veto point (or potentially a series of veto points) in ways that have been explored above in relation to ISDS mechanisms (Hawkins and Holden 2016). Without previous, real world examples to examine, as in the case of ISDS, we are forced to speculate about the effects on health. However, it is highly likely that health policies, where they might undermine corporate profits or business models, would be challenged through such measures, creating a bias towards the status quo. The ability of external actors to see and comment on domestic legislation, prior to its adoption by democratically elected governments, represents a key development in the international trading regime. It creates the potential for foreign governments and transnational corporations to influence policy debates at the earliest stage of the pro­ cess, when it is most likely these actors can amend proposals and shape the content in ways amenable to their particular interests. The proposals would create a potential prelegislative ‘veto point’, which proposals would have to negotiate before becoming law. The ability to stymie or water down proposed measures before they come into force offers a significant strategic advantage to corporate actors wishing to shape the regula­ tory environment. In this sense, regulatory cooperation mechanisms may represent an even greater cause for concern for global health advocates than ISDS mechanisms, if they are able to block or dilute proposals for food safety standards or other laws designed to protect public health.

Political Struggles over the New Agreements The controversy surrounding the issues discussed in this section led to the mobilization of civil society groups against TPP, TTIP and CETA and heated debate in all countries party to the agreements. Against the backdrop of the PMI ISDS disputes with Uruguay and Australia, this led to discussion during the negotiation of TPP about whether tobacco should be ‘carved out’ of the agreement’s ISDS provisions (Sy and Stumberg 2014). In an unprecedented move, it was ultimately agreed that there should be a form of tobacco carve out from the ISDS provisions of TPP, although states would have to ‘opt in’ to these alternative arrangements. This significantly weakens the carve out and means that industry actors can lobby governments on an individual basis not to apply it. Moreover, as McGrady (2007) has observed, the exclusion of tobacco from one trade or investment agreement may be undermined by its inclusion in other agreements, given TTCs’ ability to venue shop. Moreover, while specific carve outs for tobacco products may be regarded as a step forward for tobacco control, they raise questions about the adequacy of protections for other areas of public health policy under trade and investment

440   Chris Holden and Benjamin Hawkins agreements, including those related to alcoholic drinks and processed foods (Hawkins and Holden 2016). In the TTIP negotiations, the ISDS provisions became so controversial that the European Commission proposed replacing ad hoc adjudication panels with a perman­ ent investment court system (ICS). This idea has now been incorporated within CETA. Similarly, initial proposals for a highly institutionalised form of regulatory cooperation, through the creation of a regulatory cooperation council, were watered down in draft texts of the agreement released by the European Commission in March 2016. These were replaced by vaguer commitments to create regulatory cooperation mechanisms, which may be less formalised but will also be less transparent and equally able to shape policy debates. Delaying agreement on the precise form of the mechanism until after the agree­ ment is finalised grants far-reaching delegated powers to the European Commission and the US government to put in place practises with significant democratic conse­ quences, without the degree of scrutiny to which they are subjected during formal trade negotiations and ratification procedures. The processes of ratification of trade and investment agreements allow us to see the importance of domestic political institutions for the success or failure of such agree­ ments. National parliaments, as well as the European Parliament, have an important role in deciding whether agreements are ratified and can therefore exert influence over the contents of those agreements, even where they cannot directly amend them. In the United States, Congress is required to ratify such agreements, but ‘fast track’ or ‘trade promotion’ authority has usually been granted to the president, under which Congress’s power is limited to passing or rejecting the treaty text as a whole, without the ability to make detailed amendments to its provisions. In the EU, where an agreement is designated as a ‘mixed’ agreement, that is, an agree­ ment that includes areas of national as well as EU competence, agreements must be ratified not just by the European Parliament but also by national governments in accordance with their own constitutional requirements. This requires the agreement of twenty-eight national and ten regional parliaments. In the case of CETA, the signing of the agreement was delayed due to the opposition of the Walloonian regional government in Belgium. A last-minute round of shuttle diplomacy amongst Canada, the EU member states, and regional administrations led to the addition of supplementary protocols to the agreement to provide the Walloonian Assembly with further guarantees of its right to regulate in the public interest and its ability to guarantee strong labour market, environmental, and consumer standards. The agreement was signed in a rearranged ceremony on October 30, 2016, two days later than planned. At the time of writing, the ratification process was yet to be completed. National governments must also take account of public opinion on agreements when seeking re-election, with TTIP becoming a key political issue in many EU member states. In the United States, both TTIP and TPP, as well as the existing North American Free Trade Agreement (NAFTA) amongst the United States, Canada, and Mexico, were key issues in the 2016 presidential election, with Donald Trump stating that he would withdraw the United States from TPP upon entering office and seek to renegotiate

Trade and Investment Agreements   441 NAFTA. The degree to which TTIP became a political issue on both sides of the Atlantic may explain why negotiations for it ultimately may not be completed.

Conclusion Trade and investment agreements have important implications for health and tend to reduce the ‘policy space’ within which national governments can make health policy. Measures to protect public health that would otherwise violate trade law must be jus­ tified on the basis of necessity and formulated so as to be as least trade restrictive as possible. The WTO is the primary multilateral forum within which states can negotiate trade deals and initiate disputes with each other when they think these have been violated. Yet WTO agreements are not the only form of international trade law; the multilateral trade regime encapsulated within the WTO is overlaid with multiple bilateral, regional, and plurilateral agreements, which together constitute a confusing ‘spaghetti bowl’ of agreements (Hawkins and Holden 2016). Nevertheless, the WTO has provided an overarching institutional structure which, since its creation in 1995, has provided a relatively ordered and primarily multilateral approach to trade bargaining. This multi­ lateral regime began to come under strain as the Doha Round fell into deadlock, with the United States and the EU, in particular, seeking new ‘mega-regional’ agreements outside of the WTO’s auspices. These new agreements, in turn, provoked substantial civil society opposition in both the United States and the EU, as citizens began to ques­ tion the value of ever-greater liberalisation and new pro-corporate legal mechanisms. As the politics of trade becomes increasingly more contentious in the second decade of the twenty-first century, it remains unclear whether there will be a continued move to greater trade and investment integration globally. The election of Donald Trump and the ‘Brexit’ vote in the United Kingdom indicated a rising tide of economic nationalism and a backlash against neo-liberal forms of globalisation. While the UK government’s vision, at the time of writing, was one of continuing neo-liberal integration within the world market outside of the EU, in the United States President Trump had indicated a desire to abandon TPP and possibly TTIP, to renegotiate NAFTA, and even to take pro­ tectionist measures against other states in a manner that might violate WTO law. Trump’s agenda has caused greater uncertainty about the progress of the global trade system, with a turn away from the post–World War II liberal trading order towards a more volatile and nationalistic approach to international relations. It signifies a more instrumental approach to international politics, in which the stability of global gov­ern­ ance is of secondary importance to power-play between states, so that key aspects of contemporary global governance may be threatened, including the pre-eminence of the WTO in trade relations. It is unclear precisely what the impact of these developments might be on health policy at the national and global levels, although it raises the spectre that health issues may be sacrificed to the pursuit of a more narrowly conceived view of national economic interest.

442   Chris Holden and Benjamin Hawkins

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Trade and Investment Agreements   443 Hurt, Richard D., Jon O. Ebbert, Anhari Achadi, and Ivana T. Croghan. 2012. ‘Roadmap to a Tobacco Epidemic: Transnational Tobacco Companies Invade Indonesia.’ Tobacco Control 21: 306–312. doi:10.1136/tc.2010.036814. International Centre for Trade and Sustainable Development (ICTSD). 2014. ‘Indonesia Announces Deal with US on Clove Cigarettes Trade Dispute.’ Bridges 18 (33). https://www .ictsd.org/bridges-news/bridges/news/indonesia-announces-deal-with-us-on-clove -cigarettes-trade-dispute. Jarman, Holly. 2015. The Politics of Trade and Tobacco Control. Basingstoke, UK: Palgrave Macmillan. McCabe Centre for Law and Cancer. 2014. ‘United States–Clove Cigarettes WTO Dispute.’ http://www.mccabecentre.org/knowledge-hub/current/cloves. McGrady, Benn. 2007. ‘Trade Liberalisation and Tobacco Control: Moving from a Policy of Exclusion Towards a more Comprehensive Policy.’ Tobacco Control 16: 280–283. doi:http:// dx.doi.org/10.1136/tc.2006.019141. McGrady, Benn. 2012. ‘Implications of Ongoing Trade and Investment Disputes Concerning Tobacco: Philip Morris v. Uruguay.’ In Public Health and Plain Packaging of Cigarettes: Legal Issues, edited by Tania Voon, Andrew Mitchell, Jonathan Liberman, and Glyn Ayres, 173–199. Cheltenham, UK: Edward Elgar. McGrady, Benn, and Alexandra Jones. 2013. ‘Tobacco Control and Beyond: The Broader Implications of United States–Clove Cigarettes for Non-Communicable Diseases.’ American Journal of Law & Medicine 39: 265–289. Myers, Matthew. L. 2016. In Victory for Health, Appellate Court Overturns Misguided Ruling Regarding FDA’s Tobacco Advisory Committee. Statement of Matthew L. Myers, President, Campaign for Tobacco-Free Kids. https://www.tobaccofreekids.org/press_releases/post /2016_01_15_fda. Needham, Vicki. 2014. ‘US, Indonesia Settle Fight over Clove Cigarettes.’ The Hill, October 3. http://thehill.com/policy/finance/219755-us-indonesia-settle-clove-cigarette-dispute. Rock, Valerie J., Shane P. Davis, Stacy L. Thorne, Kat J. Asman, and Ralph S. Caraballo. 2010. ‘Menthol Cigarette Use Among Racial and Ethnic Groups in the United States, 2004–2008.’ Nicotine & Tobacco Research 12 (S2): S117–S124. doi:https://doi.org/10.1093/ntr/ntq204. Saul, Stephanie. 2008. ‘Opposition to Menthol Cigarettes Grows.’ New York Times, June 5. http://www.nytimes.com/2008/06/05/business/05tobacco.html. Siegel, Michael. 2011. ‘A Lost Opportunity for Public Health: The FDA Advisory Committee Report on Menthol.’ New England Journal of Medicine 364: 2177–2179. doi:10.1056 /NEJMp1103403. Smith, James. 2004. ‘Inequality in International Trade? Developing Countries and Institutional Change in WTO Dispute Settlement.’ Review of International Political Economy 11 (3): 542–573. doi:10.1080.0969229042000252891. Smith, Richard D., Carlos Correa, and Cecilia Oh. 2009. ‘Trade, TRIPS, and Pharmaceuticals.’ The Lancet 373 (9664): 684–691. doi:https://doi.org/10.1016/S0140-6736(08)61779-1. Sy, Deborah  K., and Robert  K.  Stumberg. 2014. ‘TPPA and Tobacco Control: Threats to APEC Countries.’ Tobacco Control 23 (6). doi:http://dx.doi.org/10.1136/tobaccocontrol -2014-051900. Tallberg, Jonas, and James McCall Smith. 2014. ‘Dispute Settlement in World Politics: States, Supranational Prosecutors, and Compliance.’ European Journal of International Relations 20 (1): 118–144. doi:10.1177.1354066111434519.

444   Chris Holden and Benjamin Hawkins Tobacco Free Kids. n.d. ‘The Anti-Tobacco Trade Litigation Fund.’ http://global.tobaccofreekids .org/en/about_us/trade_litigation_fund/. Tobacco Products Scientific Advisory Committee (TPSAC). 2011. ‘Menthol Cigarettes and Public Health: Review of the Scientific Evidence and Recommendations.’ Tobacco Products Scientific Advisory Committee. Submitted to FDA March 23. http://www.fda.gov/downloads /AdvisoryCommittees/CommitteesMeetingMaterials/TobaccoProductsScientificAdvisory Committee/UCM269697.pdf. Tversky, Amos, and Daniel Kahneman. 1974. ‘Judgment under Uncertainty: Heuristics and Biases.’ Science 185 (4157): 1124–1131. doi:10.1126/science.185.4157.1124. Van Harten, Gus. 2007. Investment Treaty Arbitration and Public Law. Oxford: Oxford University Press. Vateesatokit, P., B. Hughes, and B. Ritthphakdee. 2000. ‘Thailand: Winning Battles, but the War’s far from Over.’ Tobacco Control 5: 1079–1088. doi:http://dx.doi.org/10.1136/tc.9.2.122. World Health Organization/World Trade Organization (WHO/WTO). 2002. WTO Agreements and Public Health: A Joint Study by the WHO and WTO Secretariat. Geneva: World Health Organization/World Trade Organization. World Trade Organization (WTO). 2010. ‘European Communities—Measures Affecting Asbestos and Products Containing Asbestos.’ https://www.wto.org/english/tratop_e /dispu_e/cases_e/ds135_e.htm. World Trade Organization (WTO). 2014. ‘United States—Measures Affecting the Production and Sale of Clove Cigarettes.’ https://www.wto.org/english/tratop_e/dispu_e/cases_e/ds406_e .htm. World Trade Organization (WTO). 2016. ‘European Communities—Measures Concerning Meat and Meat Products (Hormones).’ https://www.wto.org/english/tratop_e/dispu_e /cases_e/ds26_e.htm. Zajac, Andrew. 2011. ‘FDA Panel Weighs Menthol Cigarette Ban.’ Chicago Tribune, March 20. http://articles.chicagotribune.com/2011-03-20/business/ct-biz-0319-menthol-cigarettes -20110320_1_menthol-target-black-consumers-fda-panel.

chapter 23

The Gl oba l Politics of Hea lthca r e R efor m Solomon Benatar, David Sanders, and Stephen Gill

In this chapter we examine the global politics of healthcare reform over the past four decades, which we see as an essentially ideological and political struggle that destroyed the historic compromise of the post-war order. This transformation served not only to liberate market forces, but also (as the Left weakened through the economic crises of the 1970s and early twenty-first century) to progressively allow capital to triumph over labour in a restructured world order in which communism and the Left were in retreat against the forces of the Right. These changes were driven by the interests of large c­ orporations and finance houses, pro-market theoreticians and think tanks, as well as well-funded ideologues and political leaders who espoused neo-liberalism. We emphasise that the central concept of neo-liberalism—one that is said to underpin all the cherished liberties that neo-liberals wish to extend and enhance—is the inviolability of private property rights. Thus the debate over neo-liberalism versus socialism concerns the degree to which private property rights become sovereign in the determination and direction of the social and political process and how far and under what conditions they can be regulated and taxed in order to pay for the generalised provision of public goods such as education and health. After setting out the historical context of contemporary debates, we describe the call to recognise health as a basic need and human right through the health for all (HFA) movement. This was to be achieved through a strategy of primary healthcare (PHC), with its focus on creating more equitable distribution of and affordable access to ­medical care, and by addressing the social determinants of health. We argue in this

446   Solomon Benatar, David Sanders, and Stephen Gill chapter that reform debates were shaped by a dialectic between the opposing ideas of (a) healthcare services as a social good governed by a concept of social efficiency and (b) the notion of a ‘market civilization’ governed by neo-liberal political and ­pro-market forces (Gill 1995). Social efficiency considers the primary elements of the entire social process as ­germane to the general health of the population. In more normative terms, the concept of a social good is that it should be available to anyone by virtue of being a member of a society, not as an economic good or commodity that is only available on the basis of the ability to pay in the marketplace. By contrast, we discuss the rise of neo-liberalism, which recasts citizens as consumers, with market forces as key drivers for allocative decisions in the making of social policy. Furthermore, in a pure market system, certain goods, such as healthcare and food, are only available to those who have the income to buy them in the marketplace, and so the market is the ultimate arbiter of whether one goes hungry or receives adequate care, irrespective of the ethos of medicine as exemplified by the Hippocratic oath. This ­concept of market-based efficiency became central to the ideas of what became known as the Washington Consensus, which supported reduced public expenditure on social services and a strengthening of the private sector. Robust protections for individual/ private property rights, enhanced market freedoms, and trade liberalisation were also deemed the best means of advancing economic growth and human well-being (Harvey 2005). Driven by the goals of economic growth and profit maximisation, the basic conditions shaping health and well-being were transformed (Lee et al. 2002; Gill and Benatar 2016a). In this way, neo-liberalism redefined the political, legal, cultural, social, and scientific spheres within and across countries worldwide. This effectively replaced PHC as originally envisaged with a narrower set of predominantly medical-technical interventions, identified primarily by their cost-effectiveness and directed at priority health problems, but largely neglectful of their social epidemiology. We conclude this chapter with a critical analysis of healthcare reform since the ­global financial crisis. We argue that neo-liberalism operated powerfully across at least five domains in the healthcare sector—politics, financing, professional activities, institutional governance mechanisms, and the entitlements and choices of citizens— and became a major driver of increasing costs of healthcare. Concomitant effects included the neglect of public health and increasing difficulty in achieving universal access to healthcare.

The Context for Contemporary Debates Prior to the twentieth century, health and illness were largely interpreted through a ­minimalist understanding of the structure and function of the human body/person. Healthcare was almost entirely dependent on diagnosis through clinical interpretation

Global Politics of Healthcare Reform   447 of described symptoms and observed signs, supported by only simple confirmatory investigations. The scientific basis of medicine was rudimentary, and the general ­disposition of social classes to disease was marked by substantial inequality. Paucity of therapeutic options—as well as the unequal effects of housing and nutritional conditions—was compensated for by beliefs in deities, diets, traditional remedies, natural forces, and indeed the value of caring for others in the manner expected of physicians, many of whom practised medicine because of altruism or a ‘spiritual calling’ to serve their fellow beings. In the early twentieth century, in the English-speaking world an ideology of ‘health through the application of science’ was restimulated by the Flexner report on medical education (Flexner 1910).1 Many scientific advances had been achieved by this time and were progressively introduced into medical practise under a mix of financing mechanisms. For example, in the United Kingdom, by the 1930s this mix included social insurance, private insurance, out-of-pocket payments, and some funding of healthcare systems through general taxation. The question of how healthcare could and should be funded and delivered both efficiently and equitably became a new focus of attention during the Great Depression and the subsequent rebuilding of the world economy after two prolonged world wars. The Great Depression had been triggered to a large extent by an over-reliance on market mechanisms in governing the world political economy, leading to a general repudiation of liberal capitalism and the emergence of a variety of statist and socialist ideologies, as well as fascism, Nazism, and other forms of reactionary authoritarianism. The Soviet Union provided an alternative to capitalist forms of governance. By the 1930s the old liberal capitalist order was widely perceived as unsustainable, and after the most destructive war in history, a new world order emerged. By 1939 the question of the ­survival of capitalism was a very real one, and in order to defeat the Axis powers the unimaginable happened, as the Soviet Union, the United States, and the United Kingdom formed an alliance to defeat Hitler, Mussolini, and the Japanese militarists. For capitalism to survive within that order required that a historic compromise be made, involving both capital and the necessary inclusion of labour and the Left in the governing practises of the major capitalist countries that would later become the Organisation for Economic Co-operation and Development (OECD). In Europe conditions emerged for the implementation of innovative scientific advances made initially under the influence of wartime military activities. These efforts were subsequently allied to the creation of the welfare state, which socialised risk for the general population and facilitated universal access to healthcare free at the point of delivery. These transformations stimulated economic growth and minimised precariousness and economic uncertainty, which had tended to undermine the general health of populations. The newly created British National Health Service (NHS) was one of the best-known examples of this new form of socialisation of risk allied to interventionist forms of state planning, principally inspired by Keynesian economic thinking that took hold, to a greater or lesser extent, in a range of different sets of capitalist arrangements across North America and Europe. The enshrined core principles of the NHS were that access

448   Solomon Benatar, David Sanders, and Stephen Gill to healthcare should be free at the point of entry, with rationing determined by ethical considerations of clinical priority. The underlying idea was equitable access to effective promotion of health and provision of healthcare, given constrained resources and competing priorities, through taxation (National Insurance) and top-up payments to avoid reducing the healthcare system to a poor-quality core. This was a modified form of socialism, underpinned by Keynesian economics and very progressive taxation. For example, in the United Kingdom high-income earners were taxed at 90 percent of their earnings beyond a certain threshold. Although it is easy to romanticise this period, in key respects it formed the framework for post-war public policies underpinned by a spirit of solidarity and shared destiny with fellow citizens. In addition to universal healthcare and progressive taxation (both of incomes and capital gains), this economic agenda also raised the necessary resources for investment in infrastructure for education, transportation, and other components of the welfare state. This was therefore the beginning of an era of great hope for a majority of people, particularly in the more affluent regions—in Europe and later throughout much of the world—that the application of scientific and medical advances to everyday healthcare would be the route to long and healthy lives for all. Evidence suggests that over the next three decades much was achieved through these ideals and the development of socially supportive structures. It must be emphasised, however, that these structures were limited to a small proportion of the world’s population, principally located in OECD countries. By the 1970s two periods of deep economic crisis created fiscal pressures on governments worldwide, notably in low- and middle-income countries (LMICs), whose fiscal capabilities became severely stretched (Reuss 2009; Macalister 2011). These countries were then required to borrow from abroad, in the form of loans that came with ­conditions that required them to implement certain economic reforms. For example, the World Bank deemed these measures forms of necessary ‘structural adjustment’ in exchange for continued debt relief. The political context for this shift was that policymakers increasingly sought to return to market solutions to address economic, social, and health problems. In so doing they claimed, as did UK prime minister Margaret Thatcher, that there was ‘no alternative’ to neo-liberalism. She and other conservative leaders began to repudiate the post-war settlement and the solidaristic Keynesian political economy that went with it. She made it clear that she thought there was ‘no such thing as society’, only a collection of possessive individuals who would be governed by market forces and an entrepreneurial ethos that did not restrain operations of capitalist firms through progressive taxation. This neo-liberal political perspective was vehemently opposed to socialism and, according to Thatcher, was intended to ensure its eradication and to set the scene for increased contestation between opposing perspectives on the development of healthcare services and financing, which played out in policy reforms over the next several decades. For example, cutting taxes for the wealthy and corporations made it more difficult to fund expensive socialised healthcare systems without raising taxes from the poorer

Global Politics of Healthcare Reform   449 members of the community. It is in this context that we locate healthcare reforms of the past four decades.

Primary Healthcare: Social Solidarity and Social Goods The basic approach to healthcare, which developed in the 1950s and 1960s, emphasised rural health centres staffed by paramedical workers or auxiliaries such as medical assistants and health assistants. Promoted initially by India’s Bhore Commission, it was later developed (King 1966) into what became known as the basic health services approach (Gish 1979). Although this approach did improve coverage somewhat, it remained service-based and medicalised, with little community involvement. The disappointing implementation of the basic health services approach was the impetus behind the PHC movement, which emerged during the 1970s during a period of increased assertiveness by LMICs through the formation of the non-aligned movement and Group of 77. The basic principles underpinning PHC continued to guide global health policy over the next forty years. Remarkable progress was also achieved in improving health in China during the 1960s and 1970s through social improvements, mass campaigns, and ‘barefoot doctors’ or community health workers. By bringing together these experiences with the achievements of many small-scale, community-based healthcare projects in LMICs, mostly led by non-governmental organisations (NGOs), the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) promoted the strategy of PHC2 as the means to achieve HFA by the year 2000 (WHO 2008a). This strategy was approved with acclamation by WHO member states at a historic conference held in Alma-Ata in the then Kazakh Soviet Republic (Cueto 2004). The primary healthcare approach (PHCA) thus combined the Cold War era’s ­ideological and geopolitical divisions between Western-led market capitalism and Soviet-style development thinking with its social democratic ideals, propounded by labour movements and socialist political formations. The Alma-Ata Declaration was an application of the ‘basic needs approach’ to health development (Hoadley 1981), which had become prominent during the 1970s (Cockett 1994). Despite its affinity to socialist principles and experiences, the PHCA was broadly endorsed by virtually all WHO member states. It focused on community- and primary-level healthcare, as well as on a strong sociopolitical component. It outlined a strategy to provide more equitable, appropriate, and effective basic healthcare and to address the underlying social, ­economic, and political causes of poor health. The principles of the PHCA, within a broad horizontal endeavour, include universal access and equitable coverage; ­comprehensive care emphasising disease prevention and health promotion; community and individual participation in health policy, planning, and provision; inter-sectoral action; and appropriate technology and cost-effective use of available resources.

450   Solomon Benatar, David Sanders, and Stephen Gill How Alma-Ata and PHC gained the attention of the world’s health leadership has been described as one of the most intriguing narratives in the history of health and development (Bryant and Richmond 2008).3 By the early 1980s, however, support for a comprehensive PHCA was deemed by some—particularly economists wedded to the neo-liberal perspective as well as sundry conservative political leaders—to be ‘too ambitious’ (Walsh and Warren 1979) and not feasible given the fiscal turmoil in the world economy. In a period of increasing depoliticisation, by which core and fundamental political principles were subjected to technocratic vocabularies and discourse, the so-called comprehensive PHC began to be supplanted by what became known as selective PHC. This entailed the adoption in LMICs of selected vertical health interventions, such as growth monitoring, oral rehydration therapy (ORT), breastfeeding, and immunisation (GOBI). This selective approach became the centrepiece of UNICEF’s Child Survival Revolution, characterised as the ‘leading edge’ of PHC, to be followed by a more comprehensive approach at a later stage (UNICEF 1983,  1990,  2016). The Task Force on Child Survival and Development, supported by donors such as the US Agency for International Development (USAID), was based on the same focus on taking forward a core ­package of priority interventions. The shift of emphasis, away from principles of equity as a core value of social and ­economic development (along with inter-sectoral collaboration, community participation, and sustainability) and towards market efficiency, alongside narrow definitions of cost-effectiveness and other technocratic economic criteria, was part of a broader ideological shift towards political conservativism beginning in the 1980s (Rifkin and Walt 1986). This was coupled with a series of measures to take fundamental questions of politics and the political economy out of mainstream contestation over health policies. The belt-tightening, state-shrinking policies of neo-liberalism, prompted by problems in the world economy such as the oil crisis, rising debt, and rapid inflation, were presented to the public by governments and donor agencies as a form of ‘common-sense’ alternative to what was deemed to be bloated and inefficient state sectors. By common sense, we mean it was presented as self-evident that state-directed health systems were part of the problem rather than the solution. Neo-liberals took the offensive, backed by well-funded think tanks and against left-wing forces in many parts of the world—now bereft of an alternative geopolitical model as previously provided by the Soviet bloc—that were incapable of providing alternative solutions or an adequate defence of existing systems. Neo-liberal ideas and associated health reforms were strongly promoted by the World Bank, beginning with the 1993 World Development Report: Investing in Health (World Bank 1993). In promoting a more elaborate version of the selective PHC approach, in part, the report was a response to criticisms of the World Bank’s structural adjustment programmes. Yet rather than challenge the neo-liberal assumptions underpinning structural adjustment, the World Bank embedded them deeper in health sector reforms across the developing world. Since then its argument has tended to be the same, attributing every crisis or policy failure mainly to market-based reforms not having gone far

Global Politics of Healthcare Reform   451 enough and therefore advocating greater market involvement. Whilst there was no stand­ard package of neo-liberal health sector reforms, common policy measures included reducing the size of the state sector, shrinking the number of clinical personnel and expanding the management echelons, contracting out public services to private providers, introducing fees for service practises and insurance-based financing schemes, increasing competition amongst service providers, and decentralising ­management of healthcare facilities (Cassels 1995). Throughout the state sector, criteria from neo-liberal public management were used to transform the operation of the state sector so that it behaved as if it were competing in the capitalist marketplace. Put differently, what was occurring was simultaneously the privatisation of the state and encouraging nonstate provision of healthcare and pharmaceutical services. Several of these reforms, especially cost containment and deregulation, have had an adverse impact on the potential for PHC to be implemented effectively (WHO 2008b). There is evidence that privatisation of healthcare is undermining equity in coverage (Koivusalo and Mackintosh 2004), and the imperative of achieving greater technical and economic efficiency through ‘rationalisation’ of essential interventions has negatively impacted the ‘comprehensiveness of services’. Alongside these changes came an Orwellian shift in language. Methods such as cost-effectiveness analysis (CEA) began to be increasingly employed to define priorities in both curative and personal preventive interventions. These were consolidated as costed ‘packages’ of care, enabling rationing (Koivusalo and Mackintosh 2004). Health interventions outside the essential ‘package’ were to be funded ‘out-of-pocket’ and would be available only through the private sector, thus commercialising healthcare. A study in the late 1990s showed only 9 percent of healthcare transactions in a Tanzanian study were provided free of charge in that formerly socialist state (Mackintosh and Tibandebage 2002). The promotion of limited ‘packages’ of care allowed the development of multitiered healthcare, with package-based safety nets for the poor, social insurance for employed workers, and private insurance for the wealthy (Sanders et al. 2011). This preoccupation with cost-efficiency through ‘rationalisation’ of essential interventions (a ‘core package of services’) has aggravated the privileging of single ­medical interventions and marginalising of primary prevention. Thus, handwashing by individuals to prevent enteric infections has been strongly promoted over more socialised mechanisms such as improved water supply and sanitation, with the former seen as being more cost-effective (WHO 2001). This has resulted in a kind of healthcare policy myopia, eschewing many other indirect effects of improved water and sanitation on health and nutrition—such as the saving of (mostly women’s) time spent in water collection for other health-promoting household activities, including childcare and food production—that is, more socially efficient dimensions of health. This has also contrasted with the ‘basic needs’ approach and shifted focus and activity away from the social and environmental determinants of ill-health (Anand and Hanson 2004) and the centrality of inter-sectoral actions and community participation to the PHCA. Health came to be seen as the outcome of biomedical healthcare, losing sight of the fact that health is shaped by other powerful social forces in the womb, during early childhood,

452   Solomon Benatar, David Sanders, and Stephen Gill and into adult life (Evans et al 1994). Such policies fail to recognise that improvements in health are crucially dependent on enhanced living and working conditions (Sullivan and Adler 1999). Finally, with healthcare being viewed as a commodity and as a source of maximisation of profit or minimisation of cost—either because of privatisation or because of the use of a narrow form of accounting to assess health service activity—these increasingly dominant approaches mean that the functions of community mobilisation, intersectoral action, and advocacy are unlikely to be rewarded or encouraged by the broader health system. In LMICs, narrowly ‘vertical’ (disease-focused and defined) health programmes became more prevalent. Most donor funding for health in LMICs up to the early 1990s was consequently provided in two ways: from the World Bank in the form of loans and credits and through earmarked support to LMICs from bilateral donors for vertical projects or programmes. A centrepiece of neo-liberal restructuring over the past fifteen years has been the dramatic growth of global health partnerships (GHPs) or global health initiatives (GHIs) as a new mechanism for channelling donor funds to LMICs. We argue that this new form of funding, in keeping with neo-liberal ideology, promotes private sector involvement in the reshaping of the provision of public goods. In the health sector, this is often in the form of ‘public-private partnerships’ (PPPs) associated with a veritable alphabet soup of new acronyms. These include the Global Alliance on Vaccines and Immunizations (GAVI); the Global Fund to Fight AIDS, TB and Malaria (GFATM); the World Bank Multi-country AIDS Program (MAP); and the US President’s Emergency Plan for AIDS Relief (PEPFAR). All are endowed with massive budgets and have become the major sources of health financing in the world’s poorest countries, especially for HIV, tuberculosis, and malaria (Sanders et al. 2011). Although their advent has resulted in an exponential increase in funding for certain health (especially HIV/AIDS) programmes, it is important to recognise that they have also reinforced the selective approach to PHC through countrywide, disease-specific funding mechanisms. Such programmes are usually vertically implemented and managed, and they privilege therapeutic interventions and (in selected cases) personal prevention, with little funding for promotive interventions to address ‘upstream’ determinants such as gender inequity, community mobilisation, or care. Beyond donors to health development assistance, the commercialisation and privatisation of healthcare services during this period were supported by the governments of wealthy countries and promoted through the General Agreement on Trade and Services (GATS) and many bilateral free trade agreements. In effect, these are agreements that re-regulate the provision of health and other social services and public goods by means of liberalisation—that is, opening them up to privatisation and private investment. Moreover, the inclusion of the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) in the World Trade Organization (WTO) has forced countries to accept that knowledge and innovation are commodities to be bought and sold on the world market and therefore to adopt uniform standards of intellectual property

Global Politics of Healthcare Reform   453 ­ rotection, irrespective of their stage of industrial and economic development. (Kapczynski p 2009; Reichman and Drefuss 2007). By contrast, most of the wealthy OECD countries, not least the United States, Germany, and Japan, have all promoted economic growth and development through a variety of protectionist and other interventionist policies. The emphasis of GHIs on treatment and products to address diseases has deflected the focus from environmental and social determinants and from effective prevention activities, and thus from comprehensive PHC. The GHIs are also fragmenting and undermining country-led approaches and increasing the opportunity costs for already overstretched ministries of health. Whilst much progress was made through such PPPs in supplying antiretrovirals (ARVs), from the early 1980s to the second decade of the twenty-first century, there has been little coordination amongst different GHIs. They are seldom integrated into the health systems of the recipient countries (Biesma et al. 2009). This has major implications for the sustainability of programmes after the funding from a particular GHI declines or ends. These reforms have thus had an adverse impact on PHC implementation and equity in coverage (Koivusalo and Mackintosh 2004) through prioritising vertical healthcare delivery programmes (e.g., for HIV/AIDS) and new forms of public administration (Rudin and Sanders 2011). This strategy strikingly contrasts with successful active development state strategies in East Asia, where neo-liberal policy reforms were less eagerly adopted (Kasahara 2013). It is notable that within medical practise, the thrust away from healthcare as a desirable publicly supported service towards private medicine has encouraged the development of what has been called a medical/industrial complex driven by its own motives and priorities, which may be at variance with traditional conceptions of public goods and social efficiency (Relman 1980). Similarly, opportunities to undertake scientific and medical research, enhanced by the freedom of researchers to choose what to research, are heavily influenced by the choices of wealthy funders (e.g., the Bill and Melinda Gates Foundation). These priorities determine what research to support and contrast with the relative paucity of public research funding (Giroux 2007). On the one hand, these developments are attractive to many physicians undertaking complex and expensive medical/surgical interventions (on a fee-for-service basis) and to the profit-maximising pharmaceutical industry (Abraham 2016). On the other hand, they are anathema to those physicians concerned about any conflict of interest and who are committed to universal, affordable, equitable, and sustainable access to healthcare. The ways in which neo-liberal economic policies have played out have varied in different national contexts. They have taken hold perhaps most powerfully in the United States (Physicians for a National Health Program 1999; Angell 2002; Zhou 2001; Tavernise 2016), supported by strong lobbying from the pharmaceutical and medical insurance industries and medical professional organisations. They have had less influence in countries like Germany (Heier 2015; ‘Health Care in Germany’ n.d.), the United Kingdom (UK Department of Health 2016), Japan (Imai 2002), and Taiwan (Cheng 2003), where there have been varying degrees of success in retaining some solidarity in the provision of healthcare (Physicians for a National Health Programme 2017).

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The Influence of the World Bank and the Washington Consensus: A Preliminary Balance Sheet The political attitudes behind the erosion of support for universal health coverage began when the World Bank’s 1981 Berg Report inspired industrial insurance schemes, user fees at public health clinics, liberalisation of the pharmaceutical trade, and outsourcing of some public health activities—all early hallmarks of neo-liberal restructuring. The 1993 World Development Report (World Bank 1993) further endorsed the neo-liberal approach to health and introduced the term ‘disability adjusted life years’ (DALYs) as a new measurement of the burden of disease, influenced significantly by the consideration of losses to economic productivity. The neo-liberal reforms inspired by this approach aggravated health inequities, and the vulnerable poor suffered more than any other group (Rowden 2009). The initially narrow range of economic restrictions placed on low-income countries expanded into a broader package of overlapping policies within what came to be called the Washington Consensus, with its development strategies focused on privatisation, liberalisation, and macro-stability (largely price stability) policies, grounded in a strong faith in unrestricted markets and aimed at reducing the role of government, or more precisely restructuring the role of government so that it became market enabling and more limited in its ability to expropriate or nationalise corporations or private healthcare producers. The ‘standard’ reform package (promoted as ‘structural adjustment’ for indebted countries by Washington-based institutions, as described above) comprised ten steps: fiscal discipline, public expenditure priorities, tax reform, financial liberalisation, unified exchange rates, trade liberalisation, foreign direct investment, privatisation, deregulation, and full protection for an extension of private property rights (Rowden 2009). By 1984, negative impacts of implementing structural adjustment were already evident in the health of children in many LMICs. Whilst life expectancy at birth worldwide improved, from 46.5 years to 65.2 years between 1955 and 2002, life expectancy fell in sub-Saharan Africa from 50 to 46 years (WHO 2003). Although the declines in certain parts of Africa were largely due to HIV/AIDS (and to some extent have been reversed with ARV treatments [Mayosi & Benatar 2014]), they were also in part due to neo-liberal policy reforms, which coincided with the emergence and spread of HIV (Rowden 2009). By the 2000s per capita incomes in forty-five developing countries were lower than they were twenty-five years earlier. In 2003 the United Nation Development Programme’s annual Human Development Report showed falling growth rates in many developing countries, and the impacts of such policies on development have been well summarised (Rowden 2009). The UNICEF Annual Report 1987: Adjustment with a Human Face (UNICEF 1987) concluded that the main effects of the

Global Politics of Healthcare Reform   455 adjustment programmes were failure to sustain growth and adverse impacts on the welfare of children and some socio-economic groups. Moreover, the disciplines of neo-liberalism have been reflected both in the salience of market forces in determining the structure of healthcare provision and in the ways in which deviation from neo-liberal principles can be punished. For example, the WTO’s dispute settlement mechanism incorporated the principle of ‘cross-retaliation’, which was in turn included in the TRIPS Agreement, which allowed countries to use the threat of retaliation—in the form of imposition of trade sanctions—to seek compliance (Abbott 2009). The signing of the TRIPS agreement in 1994 has been followed by several template preferential bilateral trade and investment agreements between high-income countries and LMICs that demand even higher standards of (private) intellectual property rights (IPR) protection than are required by the TRIPS Agreement (Friel et al. 2013; Lopert and Gleeson 2013; Cohen-Kohler et al. 2008). The effect of the conflation of trade agreements with IPR standards has been to shrink the policy space available to developing countries to set domestic policies related to such rights commensurate with local needs, including important public health needs related to access to essential and lifesaving medicines. Returning to the Orwellian theme, it is notable that ‘good governance’, in World Bank and International Monetary Fund (IMF) language, in reality comprises norms, concepts, mechanisms, legal processes, and compliant institutions that facilitate an unequal international order underpinned by capital, the world market, and US geopolitical power. The most powerful states and transnational corporations have developed this lexicon, along with a variety of national and international mechanisms that have come to govern the global political economy, thereby extending their private property rights, protecting their investor freedoms, and creating increasingly privatised mechanisms in healthcare delivery (Gill and Benatar 2016b). However, these privatised mechanisms provide an opportunity for investors and large corporations, whilst they restructure and put pressure on the healthcare systems and health outcomes in many of the poorer countries. For example, huge financial losses have been generated for Africa through its attachment to the market structures of the world economy (Trust Africa 2017). Capital flight, tax evasion, and the growth of offshore financial centres have also stunted economic growth in the decolonised nations, with significant adverse health effects. During the 1970s the inability of many LMICs to ­service their debts forced them to comply with debt rescheduling policies. These ultimately eliminated their macroeconomic autonomy and subjected them to the World Bank’s liberalisation, privatisation, and deregulation programmes for healthcare, which had begun in high-income countries but were subsequently applied to healthcare reform in LMICs, including those in sub-Saharan Africa (Rudin and Sanders 2011). Furthermore, we note that a seldom-articulated political aspect of neo-liberalism is how it covertly undervalues the lives and health of those who lack the power and freedom to make choices that could emancipate them from their very miserable lives (Benatar 1998; Van Rensburg and Benatar 1993). This is reflected in the statement made by an economist in the early 1990s: two-thirds of all the people in the world are ‘superfluous

456   Solomon Benatar, David Sanders, and Stephen Gill from the perspective of the market. By and large we do not need what they have; they can’t buy what we sell’ (Gardels 1993). Such attitudes persist in what could be considered inadequate definitions of poverty and satisfaction with, as the World Bank has put it, ‘lifting a billion out of poverty,’ when this merely reflects increasing their income from just below US$2 per day (the World Bank definition of absolute poverty) to just above US$2 per day (Kochhar 2015; Benatar 2016a, 2016b). It is obfuscating when such minor increases in income, together with reductions in mortality under the age of five years (an inadequate measure of improvement in health) are exaggeratedly interpreted as signifying the potential for the ‘convergence of health’ within a generation (Jamison et al. 2013). Meanwhile, the Gini coefficient of income inequality continues to widen globally, with over 71 percent of the world’s population living on less than US$10 per day.4 By contrast, the ‘post-Washington Consensus’ perspective calls for a return to Keynesianism and is critical of (a) the failure of the Washington Consensus to understand basic economic structures within developing countries and (b) the focus on a very narrow set of objectives with a limited set of instruments. Accounts of these failures claim these are due to honest differences in economic analysis, in the interpretation of statistical evidence, and in historical experiences, rather than to the role of ideology and special interests (Stiglitz 2008). Yet several elements of an emerging shared view about the inadequacies of the Washington Consensus have been noted, including a consensus about two of the underlying problems: excessive belief in market fundamentalism and unfair rules made by international economic institutions that have imposed failed ­policies particularly on developing countries, including the World Bank and IMF with their ‘one size fits all’ policies that are doomed to failure (Stiglitz 2008). The question is, however, failure for whom?

Healthcare Reform since the Global Financial Crisis: Missing in Action? In 2008 all WHO regions reaffirmed commitment to the policy of PHC, giving WHO the mandate to build upon its principles. The 2008 World Health Report focused on PHC and explicitly acknowledged the previously affirmed centrality to PHC of the social determinants of health (Werner and Sanders 1997). However, in contrast to the founding declaration, it did not interrogate the global economic dispensation or call for a new international economic order (NIEO) as proposed during the 1970s by the ‘non-aligned movement’ to replace the Bretton Woods system. Whilst the latter had benefited the leading states that had created it, the NIEO would favour LMICs by promoting their interests through improved terms of trade, increased development assistance, and reductions in developed-country tariffs. Although PHC has been adopted as a global strategy since the 1970s, it has been more enthusiastically embraced by LMICs.

Global Politics of Healthcare Reform   457

Inequality, Austerity, and Erosion of Professionalism By the early twenty-first century neo-liberalism was embedded in, and operated powerfully across, at least five domains in the healthcare sector: politics, financing, professional activities, institutional governance mechanisms, and the entitlements and choices of citizens. The centrality of freedom of choice within neo-liberalism has become a major driver of increasing costs of healthcare. Although freedom to choose in healthcare is highly prized, there are complexities associated with such choices that lead unexpectedly to situations in which patient choice is seriously and covertly limited (McLaughlin 2001). A market and consumerist ideology encourages unlimited wants as the norm. The freedom of physicians to use new diagnostic and therapeutic techniques that have transformed healthcare, combined with the evolution of medical decision making to enhance patient freedom to make choices, and the commodification of healthcare have become major drivers of increased healthcare costs (Tan and Ong 2002; Fett 2000; Barbash and Glied 2010; Canadian Institute for Health Information 2014; Smith et al. 2000), resulting in the need for more explicit resource allocation ­policies (Center for American Progress 2012). Neo-liberalism has progressively diluted professionalism and gradually moved professionals into activities heavily influenced by technology, the market, and bureaucratic ideological forces (Morone 1993). The health professions have thus not escaped general trends, and there is widespread ­evidence of, or at least perceptions of, the erosion of professionalism (Freidson 2001; RCP 2005). At the same time, one of the most fundamental effects of the policies institutionalised since the global financial crash—that is, measures to save global capitalism from implosion—has been to flood world markets with liquidity in order to sustain ­economic growth. However, such measures have stretched public finances and imposed widespread austerity measures to help cut public deficits and fund the bailouts, thus socialising risks for corporations and wealth holders and implicitly ­supporting greater privatisation of risk for the general population. For example, in the European Union the central measures are associated with what has been called ‘quantitative easing’, which is a technocratic neologism for monetary policies by central banks that involve buying up troubled assets and extending loans at very cheap rates of interest in ways that are intended to boost asset prices. By definition, only the wealthy, investors and corporations, hold significant assets. The poor have no assets, and therefore these policies are of little use to them—at least directly. Governments could have redistributed income through fiscal policies, but they chose not to. Instead, public expenditures, including for health, have been cut back in order to boost the financial sector through monetary policies administered by central banks that have been made ‘independent’ in the neo-liberal era. ‘Independent’ means that monetary policy is made by private banks, other private financial interests, and ­sympathetic neo-liberal economists without government control. Trade unionists and heterodox economists do not sit on the governing boards of these central banks (Gill 2017).

458   Solomon Benatar, David Sanders, and Stephen Gill The opportunity costs of these emergency measures can therefore be counted in the healthcare benefits foregone in order to bail out the banks and the financiers. It is notable that this set of measures has been accompanied by the greatest increase in global inequality in recorded history; a mere eight men together now hold more wealth than half of the world’s population, almost 3.75 billion people (Oxfam 2017). A broader ­political economy analysis suggests that the neo-liberal responses to the crisis have been at the cost of undermining the material dimensions of health for a majority of the world’s population. This is being increasingly acknowledged, not least through the stimulus of Thomas Piketty’s work in shaping debates in sociology, political science, and economics (Piketty 2014) by a wide range of intellectuals who are grappling with the issues it raises (Boushey et al. 2017).

Population and Public Health Despite all the medical and healthcare progress being made, by the end of the twentieth century patterns of disease and of longevity still differ markedly across the world. Whilst life expectancy at birth has continued to increase worldwide, it still ranges from well over seventy years in highly industrialised countries to below fifty years in some poor countries. In several sub-Saharan African countries, gains in longevity achieved during the first half of the twentieth century were rapidly reversed by the HIV/AIDS pandemic, although longevity is improving with the introduction of antiretroviral therapy (ART) (Mayosi and Benatar 2014). The emergence and spread of infectious diseases like Avian flu, HIV, SARS, MERS, Ebola, and more recently Zika have become new focal points of popular concern about global health. Not surprisingly, these infections tend to arise in the poorest countries, where intimate and undesirably close interactions between humans and animals, often the result of widespread ecological changes wrought by extractive industries that penetrate previously uninhabited areas, facilitate the spread of infective agents from animals to humans. These epidemics are not disconnected events and cannot be viewed superficially as isolated biomedical crises arising from transmission of an animal virus to humans, to be dealt with only through emergency medical rescue processes. They are instead milestones along the pathway of complex human behavioural interactions with nature over millennia (Garrett 1994; McMichael 2014; Boyden 2004; Benatar 2005a; Shah 2015; Hotez and Pelperl 2015). Such infections cause most problems locally, as ­living conditions are conducive to their spread, and public health systems/measures to prevent it are very poorly developed. These diseases can spread rapidly across the whole world, with the potential to kill millions, given the ease and extent of travel in a ­globalised world and the many pockets of severe poverty even within the G20 countries (Hotez and Pelperl 2015). The post-2007 global financial crises and the 2014 Ebola epidemic in West Africa highlighted inadequacies in global health awareness, the weakness of health systems, the failure generally of epidemic preparedness, and the failure specifically to develop

Global Politics of Healthcare Reform   459 vaccines and drugs for use in good time and to instal well-known public health measures necessary to prevent the rapid spread of infection. These are notable failures, given several small epidemics since the emergence of Ebola in 1976 and knowledge of the rapidly fatal outcome of this infection (Sanders et al. 2015). The deepest, less easily perceived, and largely ignored explanation is that the epidemic was one of many manifestations of failed human and social development that have brought some countries (e.g., Liberia, Sierra Leone) and the world to dangerous ‘tipping points’ (Benatar et al. 2009; Benatar 2015).

Neglect of the Social Determinants of Health and Pandemic Control It is now increasingly being acknowledged that the long-recognised, but largely ignored, causes of poor health and disease are ultimately rooted in the social determinants (living conditions) and the societal determinants (political and economic forces) that differentially impact people’s lives locally and globally (Lee 2003; Birn 2011). Upstream causal forces include the structure of the global political economy; corruption; the distorted application of values such as freedom and human rights (with a focus on ‘freedom to’ and on ‘civil and political rights’, and with neglect of ‘freedom from’ and ‘social, cultural, and economic rights’); and demographic changes resulting from wars, refugees, and ageing populations. Lack of visionary local and global leadership is central to creating and perpetuating an unstable, unsustainable trajectory of human ‘progress’ towards what has been labelled a ‘global organic crisis’ (Gill 2012, 2016). This comprises many overlapping and interlinked components within systematically entrenched forms of local and global structural social violence (Farmer 2003; Lee 2017). Yet WHO and other institutional players have attempted various forms of pandemic control and global health gov­ern­ ance, with limited success (Smith and Upshur 2015). These epidemics have also accelerated development of ‘health security’ and ‘health diplomacy’ as new aspects of global health in a new vocabulary designed to give credibility to the work of the wealthy in poor countries (Kevany 2015) and, ultimately, to protect the ‘developed’ world from contagion. Serious criticisms have focused on the inability to solve such global problems from within the belief system that has been a major contributor to the problem (Gill and Benatar 2016a). It has been previously argued that substantial improvements in global health will depend on acknowledging that poor health at the level of whole populations reflects systemic dysfunction in a complex world, and that improving global health will require greater moral imagination (the ability of individuals and communities to empathise with others) to break the impasse we currently face in improving global health (Benatar 2005b; Benatar and Brock 2011; Gill 2012; Benatar et al. 2016). It is against this background that we have reviewed some of the specific measures and arguments that have been presented concerning the governance of global health (Gill and Benatar 2016a).

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Universal Access to Healthcare Recent insights regarding the shortcomings of neo-liberal policies have prompted renewed interest in universal access to healthcare and the need to build and support resilient public health systems. Today UHC is being strongly promoted as a panacea for health inequities and is manifesting in various jurisdictions as voluntary insurance schemes, autonomous programs for the poor only, and parallel private insurance or copayments for services beyond a basic package (Cotlear et al. 2015). Long advocated by WHO, UHC is again being described as a major global political goal and ethical endeavour (Chapman 2016; Reis 2016). However, as stated previously, proposed mechanisms to achieve UHC differ widely, with tax-funded and solidarity based initiatives constituting the minority. Reis cites the Ebola virus outbreak of 2014–2015 as a clear demonstration of the need for national, as well as international, support for failing health systems. Solidarity and good governance within countries, alongside international solidarity, are being identified as central requirements, together with fair priority-setting mechanisms and engagement of people/communities in the process of allocating resources. These are admirable aspirations (O’Connell, Rasanathan, and Chopra 2014; Reich et al. 2015; Sengupta 2013), but UHC must be seen in the broader context of a world in which 70 percent of people (about five billion) live on less than US$10 per day (including one billion people on less than US$2/day and a further four billion people on US$2–10/ day), and in which WHO has failed to demonstrate good governance of health nationally and globally (Smith and Upshur 2015; Gill and Benatar 2015). Serious shortcomings in the way healthcare is provided and funded in many high-income countries (Rosenthal 2017) do not inspire confidence in the recommendations being made to LMICs. The problem of access to affordable healthcare in India, for example, illustrates the magnitude and complexity of the problem and failure to consider the crucial role of the social and societal determinants of health (Barik and Thorat 2015). In this context, the central responses to challenges are currently focused on generating resources to cover costs, deciding how health services should be delivered (through equitable, horizontally arranged healthcare systems or through parallel vertical programs), and how healthcare professionals should be remunerated. Politically driven disjunction between economic growth and associated advances in science, technology, and medical care and the ability to use these to improve health more equitably, within countries and more widely, has also reshaped the practise of medicine (and indeed the role and image of health professionals) and the extent to which ‘healthy’ life can be promoted. A specific result is erosion of the political will and social capacity to reproduce the caring social institutions (health, education, child nurturing) so essential for healthy societies (Bakker and Gill 2003). After thirty years of making many errors with neo-liberal policies and their now-acknowledged adverse impacts on health outcomes, there has been some return towards the 1978 Alma-Ata ideals and the importance of primary healthcare—which includes action on the social determinants of health—with a current emphasis on the provision of universal coverage,

Global Politics of Healthcare Reform   461 although, as stated above, several proposed models to implement UHC threaten to aggravate inequities in access (WHO 2008b).

Conclusion A fuller understanding of the global politics of healthcare reform since the 1970s begins with recognition of the dominant, and opposing, political belief systems and values that have shaped the rationales for different forms of healthcare service delivery and financing. Over the past four decades, the opposing thrust of PHC and the ideology of neoliberalism have defined efforts to provide healthcare amid growing and ageing populations, medical advances, and resource constraints. The broad trend has been towards neo-liberal-defined policies and practises, which are now embedded deeply in healthcare systems worldwide, as well as in healthcare reform debates. In countries where these ideas have become most deeply entrenched, or where global initiatives have embraced their application, there is strong evidence of substantial inequities in access to healthcare and outcomes, with relative poverty playing a significant role (Wilkinson 1996; Wilkinson and Pickett 2009). Resources, technical knowledge, and capacity are available for creating more comprehensive, sustainable healthcare systems within a diverse range of high-income countries. However, ongoing economic growth and progress along a linear trajectory to extend twentieth-century advances to LMICs are unlikely under conditions of limited renewable natural resources and other constraints on continued economic growth. Making progress towards universal access to effective healthcare will require critical analysis of the global political and economic factors shaping healthcare worldwide and the boldness to make major progress, under circumstances in which the state of global population health is only one of many signs of an unstable world in a state of entropy (Benatar 2015) in what is now called the Anthropocene era (McMichael 2014). The health and lives of billions of people are being, and will continue to be, affected by the impacts of a neo-liberal market civilisation (driven by the notion of ‘consume today and forget about tomorrow’) on environmental degradation, climate change, water security, food chain integrity, population migration and displacement, redistribution and recrudescence of vector-borne diseases, and significant short-term health impacts from extreme climatic events, as well as from significant other environmental health concerns globally not directly associated with climate change. These are global problems but may have differential local health impacts, worsened by systematic disadvantaging of whole populations in a global organic crisis and a related ‘crisis of humanity’ (Robinson 2014). Neo-liberalism— with its system of values that places the dominant emphasis on market forces—sustains economic exploitation, tolerates gross abuses of basic human rights, and discounts the importance of a safe environment for future generations, all with profoundly adverse health effects.

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Notes 1. The results of this study of medical education in the United States and Canada called on American medical schools to implement higher admission and graduation standards and to mainstream science in their teaching and research. Many American medical schools fell short of the standard advocated in the Flexner Report, and nearly half of such schools merged or were closed after it was published. 2. Primary healthcare means ‘essential healthcare’ based on ‘scientifically sound and socially acceptable methods and technology, provided through universal healthcare accessible to all individuals and families in a community, with their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination.’ The concept of PHC embraces an approach to health services and includes such contributors to health as access to health services, a safe environment, and a healthy lifestyle—in essence an early version of the social determinants of health. 3. These authors also note that since Alma-Ata there have been dramatic changes in the pattern of disease, in demographic profiles, and in the socioeconomic environment, which present new challenges to PHC. Significant changes in governments’ interpretations of their roles have had implications for both policy development and globally driven health programs. 4. Some 15 percent below U$2 per day and another 56 percent between US$2 and US$10 per day (Kochar, 2015).

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466   Solomon Benatar, David Sanders, and Stephen Gill Mackintosh, M., and P.  Tibandebage. 2002. ‘Inclusion by Design? Rethinking Health Care Market Regulation in the Tanzanian Context.’ Journal of Development Studies 39 (1): 1–17. doi:10.1080/713601263. Mayosi, Bongani and Solomon R. Benatar. 2014. ‘Health and Health Care in South Africa: 20 Years after Mandela.’ New England Journal of Medicine 371 (14): 1344–1353. McLaughlin, Catherine G. 2001. ‘Health Care Consumer Choice: The Role of Information.’ In The Political Economy of Health Care Reforms, edited by Huizhong Zhou, 109–123. Kalamazoo, MI: W.E Upjohn Institute for Employment Research. McMichael, Anthony  J. 2014. ‘Population Health in the Anthropocene: Gains, Losses and Emerging Trends.’ The Anthropocene Review 1 (1):44–56. doi:10.1177/2053019613514035. Morone, James  A. 1993. ‘The Health Care Bureaucracy: Small Changes, Big Consequence.’ Journal of Health Politics, Policy and Law 18 (3): 723–739. O’Connell, Thomas, Kumanan Rasanathan, and Mickey Chopra. 2014. ‘What Does Universal Health Coverage Mean?’ Lancet 383 (9913): 277–279. doi:10.1016/S0140-6736(13)60955-1. OXFAM Report 2017. (2017). ‘Just 8 Men Own Safe Wealth as Half the World.’ https://www .oxfam.org/en/pressro om/pressrele as es/2017-01-16/just-8-men-own-s ame -wealth-half-world. Physicians for a National Health Program. 1999. ‘A Brief History: Universal Health Care Efforts in the US.’ http://www.pnhp.org/facts/a-brief-history-universal-health-careefforts-in-the-us. Physicians for a National Health Program. 2017. Health Care Systems—Four Basic Models. http://www.pnhp.org/single_payer_resources/health_care_systems_four_basic _models.php. Piketty, Thomas. 2014. Capital in the 21st Century. Cambridge, MA, Harvard University Press. Reich, Michael R., Joseph Harris, Naoki Ikegami, Akiko Maeda, Cheryl Cashin, et al. 2015. ‘Moving Toward Universal Health Coverage.’ Lancet 387 (20020): 20–26. doi:10.1016/ S0140-6736(15)60002-2. Reichman, Jerome H., and Rochelle Cooper Drefuss, 2007. ‘Harmonization Without Consensus: Critical Reflections on Drafting a Substantive Patent Law Treaty.’ Duke Law Journal 57: 85–130. http://scholarship.law.duke.edu/cgi/viewcontent.cgi?article=1330&context=dlj. Reis, Andreas. 2016. ‘Universal Health Coverage: The Critical Importance of Global Solidarity and Good Governance.’ International Journal of Health Policy & Management 5 (9): 1–3. doi:10.15171/ijhpm.2016.61. Relman, Arnold  R. 1980. ‘The New Medical-Industrial Complex.’ New England Journal of Medicine 303: 963–997. doi:10.1056/NEJM198010233031703. Reuss, Alejandro. 2009. ‘What Can the Crisis of U.S. Capitalism in the 1970s Teach Us about the Current Crisis and Its Possible Outcomes?’ Dollar and Sense Magazine. http://www .dollarsandsense.org/archives/2009/1109reuss.html. Rifkin, Susan B., and Gilt Walt. 1986. ‘Why Health Improves: Defining the Issues Concerning Comprehensive Primary Health Care and Selective Primary Health Care.’ Social Science & Medicine 23 (6): 559–566. doi:10.1016/0277-9536(86)90149-8. Robinson, William I. 2014. Global Capitalism and the Crisis of Humanity. New York: Cambridge University Press. Rosenthal, Elizabeth. 2017. An American Sickness: How Healthcare Became Big Business and How You Can Take It Back. New York: Penguin Random House. Rowden, Rick. 2009. The Deadly Ideas of Neoliberalism: How the IMF Undermined Public Health & the Fight against AIDS. London: Zed Books.

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468   Solomon Benatar, David Sanders, and Stephen Gill UNICEF. 2016. ‘The State of the World’s Children 2016: A Fair Chance for Every Child.’ https:// www.unicef.org/publications/index_91711.html Van Rensburg, Hendrick, C. J, and Solomon R. Benatar. 1993. ‘The Legacy of Apartheid in Health and Health Care.’ South African Journal of Sociology 24 (4): 99–111. doi:10.1080/ 02580144.1993.10431680. Walsh, Julia  A., and Kenneth  S.  Warren. 1979. ‘Selective Primary Health Care: An Interim Strategy for Disease Control in LMICs.’ New England Journal of Medicine 301: 967–974. doi:10.1056/NEJM197911013011804. Werner, David, and David Sanders. 1997. Questioning the Solution: The Politics of Primary Health Care and Child Survival. Palo Alto, CA: HealthWrights. Wilkinson, Richard G. 1996. Unhealthy Societies: Afflictions of Inequality. London: Routledge. Wilkinson, Richard  G., and Kate Pickett. 2009. The Spirit Level: Why Equality Is Better for Everyone. London: Penguin Books. World Bank 1981. Accelerated development in sub-Saharan Africa: An agenda for Action. Washington D C: The World Bank. World Bank. 1993. World Development Report: Investing in Health. Oxford: Oxford University Press. World Health Organization (WHO). 2001. World Health Report 2001. Geneva: World Health Organization. World Health Organization (WHO). 2003. World Health Report 2003. Geneva: World Health Organization. World Health Organization (WHO). 2008a. Primary Health Care: Now More Than Ever. Geneva: World Health Organization. World Health Organization (WHO), Commission on Social Determinants of Health. 2008b. Final Report: Closing the Gap in a Generation; Health Equity through Action on the Social Determinants of Health. Geneva: World Health Organization. Zhou, Hhuizhong, ed. 2001. The Political Economy of Health Care Reforms. Kalamazoo, MI: W. E. Upjohn Institute for Employment Research.

chapter 24

Towa r ds a Cr itica l Politica l Econom y of Gl oba l H e a lth Ted Schrecker

At least two threads of argument and analysis, which are not mutually exclusive, can be identified in the literature on political economy and health in a global context. The first treats health as a relatively new item on the agenda of international relations and implicitly or explicitly considers political economy one of several standard explanatory frameworks for that emergence, along with the usual suspects: realism, liberalism, and social constructivism. This approach is clearly relevant to some key developments in international politics that have influenced global health: the era of structural adjustment and its reincarnations, ongoing tensions over harmonization of intellectual property (IP) rights and the consequences for access to essential medicines, and the influence on the global health policy agenda of foundations based on private fortunes (Birn 2014). At the same time, the first example in particular shows the importance of recognizing that, just as within national borders, many institutions and policy processes in the international arena that have the most substantial effects on health and its social determinants have no formal remit in the area of health or commitment to considering the health impacts of their actions. This suggests the value of an expanded frame of reference in which, in the words of one standard text on global health, ‘[a]ccording to the political economy approach to health, your health is a result of social, political and economic structures and relations’ (Birn, Pillay, and Holtz 2009, 134). More specifically, the iconoclastic US epidemiologist Nancy Krieger describes the political economy perspective thus: ‘Analysis of causes of disease distribution requires attention to the political and economic structures, processes and power relationships that produce societal patterns of health, disease, and wellbeing via shaping the conditions in which people live and work’ (2011, 168; emphasis in original). This second, more critical perspective explicitly situates the origins of illness and health inequalities in unequal distributions of power and resources. This perspective is

470   Ted Schrecker the one adopted in this chapter. Stated another way, the focus is not only on the explanatory power of political economy as one among several competing approaches to global health policy and politics, but also on the political economy of health in a global frame of reference (hereafter global political economy of health, or GPEH) and the roles of transnational actors and processes. The mechanisms at work involve multiple channels or pathways, including material deprivation (or its elimination in the case of improved standards of living); the physiological effects of acute and chronic stress; the diffusion of unhealthy lifestyles, including the unhealthy diets discussed at greater length later in this chapter; changing levels of inequality and social cohesion; and changes in access to healthcare and the benefits of medical technology (Cornia, Rosignoli, and Tiberti 2009; for elaborations that do not specifically consider global influences, see Kelly and Doohan 2012; Marmot and Sapolsky 2014; Whitehead et al. 2016). Shortly before medical scientist Richard Feachem was appointed the first director of the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund), he argued that ‘globalization’, defined in terms of increased openness to trade, ‘is good for your health, mostly’ because of associated increases in national income that make possible poverty reduction and investment in health systems (Feachem 2001, 504). This claim was subsequently called into question on several counts. These included the difficulty of establishing whether trade openness leads to growth or vice versa (reverse causation); the basis on which ‘globalizing’ countries could be distinguished from ‘non-globalizers’; the difficulty of distinguishing the effects of trade liberalization from those of other policy changes and shifts in the external environment that occurred at the same time (confounders; see Kawachi and Wamala 2007, 129–132); and an accumulating body of evidence of the negative health impacts of trade liberalization (see ‘The political economy of trade and health’). An external evaluation of World Bank economic research on growth and openness to trade, on which the Feachem claim relied, concluded that ‘much of this line of research appears to have such deep flaws that, at present, the results cannot be regarded as remotely reliable, much as one might want to believe the results’ (Banerjee et al. 2006, 53). When the World Health Organization’s Commission on Social Determinants of Health was established in 2005, one of its supporting knowledge networks1 dealt with globalization and synthesized the rapidly growing body of critical work on health impacts (Labonté et al. 2009); in 2009, the third edition of a standard text on international health appeared, with a critique of global economic integration as the organizing theme for several chapters (Birn et al. 2009). By 2014 the authors of a commissioned article in The Lancet on global governance for health (Ottersen et al. 2014) focused on ‘power asymmetries’ across a range of global health issue domains; the concept also has relevance to the larger context of development policy (Abdulsamad et al. 2015). Although these are milestones in the literature, it must not be inferred that observers of the politics of global health are in agreement, or that the trajectory of views on this topic has been straightforward. For example, the index to the 900 pages of the most recent edition of another standard international health text (Merson, Black, and Mills 2012) contains not a single reference to structural adjustment, the importance of which

Critical Political Economy of Global Health   471 is described in the next section of this chapter, and the political economy perspective is largely absent from recent (and important) research on condition- or issue-specific networks in global health policy (Shiffman 2016; McDougall 2016; Smith and Rodriguez 2016; Schmitz 2016; Quissell and Walt 2016; Shiffman et al. 2016a, 2016b), although the lead investigator on this work has elsewhere recognized its importance (Shiffman 2014). Nevertheless, political economy has moved closer to the mainstream of social science research on global health, crossing the boundaries of multiple disciplines and subfields in a way that responds to the call of a former president of the American Political Science Association, David Lake (2011), for reorganizing research in political science and international relations around substantive problems rather than theoretical or methodological orientations.

Structural Adjustment and Neo-liberal Health System Reform The role of the World Bank and the International Monetary Fund (IMF) in promoting neo-liberal or ‘market fundamentalist’ (Somers, 2008) restructuring of national economies and health systems provides a case study in the political economy of health. The most important policy instrument in this context was structural adjustment lending, a practice begun circa 1980 by the World Bank and IMF as a response to external debt crises that confronted many low- and middle-income countries (LMICs). The crises arose out of several interacting circumstances: the effects of worldwide recession following oil price increases on commodity markets, which were a major source of revenue for many LMICs; aggressive lending of ‘recycled’ oil revenues by major private banks and the World Bank itself; and a sharp rise in interest rates triggered by the US Federal Reserve in 1979. Improvident borrowing by LMIC governments contributed to the crisis, and in many cases that borrowing occurred in parallel with capital flight, in effect socializing the cost of protecting the assets of the rich (see, e.g., Rodriguez 1987)—a process that at least in some regions has continued in subsequent decades (Ndikumana and Boyce 2011). Indeed, economic historian Thomas Naylor argued that ‘[t]here would be no “debt crisis” without large-scale capital flight’ (1987, 370). A temporary default by Mexico in 1982 forced the high-income world, particularly the United States, to confront the threat presented by LMIC debt to the stability of some major banks—meaning that creditor interests were always at the core of the policy response. Although the term structural adjustment was abandoned by the IMF in 1999 and by the World Bank in 2004, similar conditions continued to be applied through such mechanisms as the Poverty Reduction Strategy Programs (PRSPs), which became a prerequisite for debt relief under multilateral initiatives, and through strict limits on public expenditures for health and education, motivated by concern about potential domestic inflation and about currency appreciation that would reduce the attractiveness of exports (Ooms and

472   Ted Schrecker Schrecker 2005; Ambrose 2006; Working Group on IMF Programs and Health Spending 2007). IMF conditionalities were eventually applied to more than 75 countries (101 by 2008; Dreher, Sturm, and Vreeland 2015), with some countries involved in multiple loan programmes for varying periods of time and achieving varying degrees of compliance with their requirements. The importance of structural adjustment for the political economy of health arises from the impact of a relatively standard package of conditions, including reduction of domestic subsidies and public sector expenditure (including healthcare), privatization of state-owned assets, deregulation of domestic markets (especially labor markets, but notably also markets for agricultural products), and increased openness to imports and foreign direct investment in the interests of restructuring economies to improve their export competitiveness (Kentikelenis 2017). Adverse effects on child health and wellbeing were documented as early as 1987, in a UNICEF study of ten countries (Cornia, Jolly, and Stewart 1987), whose argument for ‘adjustment with a human face’ seemed to have little effect. Powerful descriptions of adverse health effects in Peru (Kim et al. 2000), sub-Saharan Africa (Schoepf, Schoepf, and Millen 2000), and the former Soviet Union after the application of neo-liberal ‘shock therapies’ (Field, Kotz, and Bukhman 2000) appeared at the turn of the century; a rather sympathetic review for the World Health Organization’s Commission on Macroeconomics and Health (Breman and Shelton 2001, 2007) enumerated seventy-six studies of the health consequences of structural adjustment, identifying a preponderance of findings of negative health effects, especially in Africa. More recent, multi-country statistical studies provide a clearer picture of negative effects, such as higher child and maternal mortality rates in sub-Saharan African countries during periods in which they were operating under World Bank, IMF, or regional development bank conditionalities (Shandra, Shandra, and London 2011; 2012; Pandolfelli and Shandra 2013; Pandolfelli, Shandra, and Tyagi 2014), while recognizing the complexity of the relevant mechanisms of action. Hoddie and Hartzell (2014, 1040), in a study of all countries subject to IMF conditionalities between 1985 and 1989, concluded that ‘the negative health consequences of SAPs [structural adjustment programmes] are apparent in the immediate aftermath of signing an agreement as well as years after the adoption of one of these types of loan programmes’, although the effects did lessen over time. Such longer-term effects were observed (for example) by a development assistance–funded team working in Tanzania’s public healthcare system: ‘The era of structural adjustment may be over, but the effects of earlier damage continue to cast a long shadow’ (de Savigny et al. 2004, 10). As noted, there is reason to question the claim that the era was over. The health system impacts of structural adjustment temporarily came to public attention in the wake of the 2014–2015 West African Ebola outbreak and the ‘secondary health crises’ that emerged in such areas as nutrition, malaria treatment and maternal care (O’Carroll 2014). Some observers argued that the weakness of national health systems in those West African states most affected by the outbreak was directly traceable to the legacy of IMF programmes (Rowden 2014; Kentikelenis et al. 2015), although the IMF contested that claim (Gupta 2015). Another recent multi-country study of the

Critical Political Economy of Global Health   473 relation between IMF conditionalities and public spending on health found that per capita expenditure levels were actually higher in sub-Saharan African countries operating under conditionalities, but lower in low-income countries outside the region; the authors warned that other explanatory variables were also in play and that spending might still be seriously inadequate (Kentikelenis, Stubbs, and King 2015). Apart from direct health outcomes and health system effects, a study of ninety-one countries with World Bank or IMF loan agreements found consistent negative effects on labor rights, with ‘continued participation in these programs . . . linked to continuously declining labor rights’ (Blanton, Blanton, and Peksen 2015)—important in view of the role of such rights as a safeguard against the hazardous working conditions and precarious employment that are now widely recognized as social determinants of (ill) health (Quinlan, Mayhew, and Bohle 2001; Quinlan and Bohle 2009; Benach et al. 2014). Two further points provide essential elements of context. First, it is widely, although not universally, acknowledged that the neo-liberal policies mandated by structural adjustment conditionalities have been unsuccessful on their own terms—that is, as a pathway to longer term economic growth. Joseph Stiglitz, the former World Bank chief economist who was forced out by US pressure in 1999, argues that such policies ‘led to a lost quarter-century in Africa, a lost decade in Latin America, and a transition from communism to the market economy in the former Soviet Union and eastern Europe that was, to say the least, a disappointment’ (Stiglitz 2016). Second, structural adjustment occurred in parallel with forceful World Bank promotion of market-oriented health system ‘reform’ (Basilico et al. 2013, 104–109; Rowden 2013; Keshavjee 2014, 93–96), to the point that contemporaneous literature sometimes defined health system reform as ‘those activities undertaken cooperatively between the international development banks and a national government to alter in fundamental ways the nation’s health financing and health provision policies’ (Glassman et al. 1999, 115). In 1987 the World Bank endorsed a set of policy prescriptions including partial cost recovery through user charges, expansion of insurance as a financing mechanism, strengthening ‘nongovernment provision of health services for which households are willing to pay’, and decentralizing the delivery of health services (Akin, Birdsall, and de Ferranti 1987). The World Development Report 1993: Investing in Health stated: ‘There must be a basis for believing that the government can achieve a better outcome than private markets can’ and the cost-effectiveness of publicly financed health interventions must be determined by comparison ‘with the situation created by privately financed health interventions’ (World Bank 1993, 55, 65; see generally ch. 3). The World Bank has now moderated this position, and indeed has emerged as an advocate of universal health coverage (Rodin and de Ferranti 2012; Boseley 2012), although some are sceptical about the nature and motivations of that commitment (Sengupta 2013). The reductions in access to healthcare that were associated with adoption of user fees as an element of health system reform are now widely recognized as substantial (Ridde, Queuille, and Ndour 2014). Thus, production of health and illness cannot be isolated from broader currents of development policy, the ideologies they reflect, and underlying unequal distributions of economic and political power. These are, of course, inextricably linked. The extensive

474   Ted Schrecker critical literature on the World Bank and, to a lesser extent, the IMF (George and Sabelli 1994; Desai 2003; Goldman 2005, 46–99; Woods 2006; Stein 2008, 3–51; Engel 2010, 3–75) makes it clear that a limited number of powerful high-income countries dominate the priorities and decision-making processes of both institutions, and the positions taken by the institutions must be understood with reference to the commitment of senior staff to neo-liberal precepts drawn from neoclassical economics (see in particular George and Sabelli 1994, 96–111). The former point has been stated succinctly by Woods: ‘Powerful countries define the outer perimeter within which each organization works. Often, this means particular agencies within a powerful country—such as the U.S. Treasury’ (2006, 180). The latter point is especially significant given the hierarchical internal structure of both institutions and the role of the World Bank as not only a source of development finance but also a critical node in transnational professional networks of researchers and government officials (Lee and Goodman 2002; Goldman 2007). As in many other contexts, ideologies and interests cannot be responsibly separated, as noted by a panel of social scientists reflecting on policy responses to the debt crisis: ‘An alliance of the international financial institutions, the private banks, and the Thatcher-ReaganKohl governments was willing to use its political and ideological power to back its ideological predilections’ (Przeworski et al. 1995, 5). Against this background, possible negative health impacts—if considered at all—were regarded as collateral damage, as noted with unusual candor by a team of World Bank economists writing about health and development in the former Soviet bloc following the collapse of the Soviet Union (Adeyi et al. 1997). Whatever one’s interpretation of the motivations for structural adjustment, subsequent developments have made less tenable the claim that short-term pain is justified by longer-term health and economic gain, at least for public consumption; much of the reason has to do with the increasingly visible connections between trade policy and health described in the next section of this chapter.

The Political Economy of Trade and Health The coming into force of the North American Free Trade Agreement (NAFTA) in 1994 and the establishment of the World Trade Organization (WTO) regime in 1995 represented a fundamental change in the nature of trade policy and law. Successive rounds of postwar negotiations under the General Agreement on Tariffs and Trade (GATT) led to major reductions in tariffs and quotas, which operate at the border metaphorically if not literally. These reductions had important short-term effects on the revenues available to many LMIC governments, because until recently tariffs still accounted for a far larger proportion of their revenues than is the case in the industrialized world, and in administrative terms they are far easier to collect than most alternative revenue streams

Critical Political Economy of Global Health   475 (Baunsgaard and Keen 2005; Glenday 2006; Baunsgaard and Keen 2010). Unfortunately the literature does not offer assessments of the direct and indirect health consequences of these reductions in fiscal capacity, and there is little reason to believe that these were considered in the negotiations and domestic policy choices in question. It is clear that apart from fiscal capacity issues, NAFTA and the WTO regime heralded a fundamental shift to trade policy disciplines that operate behind borders, affecting in multiple ways the policy space available to governments: ‘the freedom, scope, and mechanisms that governments have to choose, design, and implement public policies to fulfill their aims’ (Koivusalo, Schrecker, and Labonté 2009, 105). These limitations on policy space, and the generic issue of how trade policy connects to health, became visible by way of the implications for access to essential medicines of the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS). The incorporation of IP protection into the round of negotiations that culminated in the establishment of the WTO regime was driven by (mainly) US-based pharmaceutical and software firms; as Susan Sell memorably observed, ‘in effect, twelve corporations made public law for the world’ (Sell 2003, 96). TRIPS required harmonization of IP protection by 2005, although WTO members have now granted the world’s poorest countries an extension of this deadline for a number of pharmaceuticals until 2033 (Saez 2015). Against the background of the AIDS epidemic and the development of (patented, and initially ultra-expensive) antiretroviral therapies (ARTs), patent protection for pharmaceuticals quickly became the focus of political activism in both the United States and LMICs, with at least two important consequences. First, the US government retreated on its support for the pharmaceutical industry’s defense of patent protection for ARTs in Brazil and South Africa, demonstrating—at least over the short term—‘that industrialized countries that exercised trade pressures to defend the interest of their multinational industries could no longer exert pressure without repercussions at home’ (‘t Hoen 2002). These developments occurred in the face of bitter opposition from the pharmaceutical industry (Gellman 2000), and drastic price reductions on ARTs as a result of generic production made it possible for the number of people receiving ART to increase from 400,000 in 2003 to 17 million in 2015 (‘t Hoen et al. 2011; UNAIDS 2016). Although this is still less than half the number of people living with HIV, it represents one of the great success stories in contemporary global health. Second, responding to pressure both from civil society and from many LMIC governments, in 2001 the WTO Ministerial Conference adopted what has become known as the Doha Declaration, clarifying that TRIPS ‘can and should be interpreted and implemented in a manner supportive of WTO Members’ right to protect public health’ (World Trade Organization 2001). For several reasons, the impact of the Doha Declaration on access to medicines for conditions other than HIV/AIDS had until recently been limited (Beall and Kuhn 2012). Procedures for making use of the flexibilities in the Doha Declaration remain cumbersome (Kerry and Lee 2007; Attaran 2007). Both the United States and the European Union exert informal pressure not to utilize these procedures (Secretary-General’s

476   Ted Schrecker High-Level Panel, 2016; Zhou 2016). The flexibilities sometimes are vitiated by ‘TRIPS-plus’ provisions in a variety of bilateral and regional trade agreements (Roffe, Von Braun, and Vivas-Eugui 2008; Muzaka 2011; Lopert and Gleeson 2013). Numerous discussions of the politics of access to medicines and IP protection are available in the literature (see, e.g., Balasegaram, Childs, and Arkinstall 2014; ‘t Hoen 2016). A more basic problem of political economy is that when medicines are produced primarily by profit-motivated firms, little incentive exists to develop treatments for conditions that pri­ma­rily affect the poor: ‘[I]t is more profitable to develop and market Viagra than to research a new drug to treat patients with visceral leishmaniasis, a fatal disease if left untreated. Such a drug is more likely to be developed through veterinary research if it has economic potential on the pet market’ (Veeken and Pécoul 2000, 309). Two other areas of impact demonstrate the importance of a political economy perspective; each arises from the fact that contemporary trade seldom involves the textbook process of arm’s-length exchange of goods between producers located in two relatively discrete national economies. Rather, it has been estimated that 80 percent of world trade now involves complex commodity or value chains that operate across multiple national borders and are controlled by transnational corporations (TNCs) (UNCTAD 2013). Thus, contemporary trade agreements are about protecting or incentivizing investment as much as they are about conventional notions of trade. In many cases they are also (indirectly) about producing illness, in the form of people being overweight or obese. The link operates by way of an increasingly globalized food system, and associated ‘nutrition transitions’ toward commercially produced, energy-dense, and ultra-processed foods (Popkin, Adair, and Ng 2012; Monteiro et al. 2013; Malik, Willett, and Hu 2013; Anand et al. 2015). ‘[T]he main driving force now shaping the global food system is transnational food manufacturing, retailing and fast food service corporations whose businesses are based on very profitable, heavily promoted ultra-processed products, many in snack form’ (Monteiro et al. 2013, 21). Generically, liberalization of trade and investment greatly facilitated foreign investment in supermarkets, food processing and fast food, and imports of ultra-processed products (Hawkes et al. 2012; Friel et al. 2013b), such that the prevalence of overweight and obesity in some middle-income countries—such as Mexico (Clark et al. 2012)—is now comparable to that in the high-income world. Hawkes et al. (2012, 344) argue that SAPs were the first of ‘two main policy processes’ that led to transformation of the food system in LMICs, with trade agreements being the second. Public health researchers are expressing particular concern about the potential that ‘mega-regional’ trade agreements now under negotiation or awaiting ratification will further limit the ability of governments to address this phenomenon, for example by limiting options for labeling requirements and taxation of unhealthy diets (Gleeson and Friel 2013; Friel et al. 2013a; Thow et al. 2015). The background is a formidable corporate research and marketing apparatus dedicated to promoting processed food products that are highly profitable but may be unhealthy (Moss 2013) and to resisting regulatory or even public information initiatives (Taubes and Couzens 2012; Freudenberg 2014, 37–123; Kearns, Glantz, and Schmidt 2015).

Critical Political Economy of Global Health   477 Food and beverage TNCs have even been described as the ‘vectors of spread’ of ‘industrial epidemics’ associated with alcohol and ultra-processed foods (Moodie et al. 2013), and comparisons are starting to be drawn between the notorious tactics of the tobacco industry and those of the food and alcohol industries (Chopra and DarntonHill 2004; Brownell and Warner 2009; Bhojani 2015). A second area of impact involves the potential effects of investor-state dispute settlement (ISDS) provisions that create or threaten to create additional limits on policy space. These are included in NAFTA, in the mega-regional agreements, and in many of the roughly three thousand bilateral investment treaties (UNCTAD 2015a). ISDS provisions enable foreign investors (in practice, mainly TNCs) to seek arbitration through one of several dispute resolution processes in situations where the actions of a host country government are alleged to have deprived them of profits, usually including future or anticipated profits (UNCTAD 2014, 137–140). Among the distinctive features of ISDS provisions, they can be initiated directly by investors, without the need for home government approval (and thus with reduced exposure to public pressure); in many cases the question of whether or not the policy being challenged has a legitimate public policy objective is not even considered in arbitration (Kube and Petersmann 2016, 10), although most awards are binding and enforceable through domestic court systems. Not only proceedings but also final decisions may be secret, as were nine of the forty three or more decisions made by ISDS tribunals in 2014 (UNCTAD 2015b, 1). Such provisions offer investors access to a separate, parallel justice system from which citizens qua citizens are excluded. Large TNCs not only are most likely to be successful in disputes under ISDS provisions, but also have been the main beneficiaries in financial terms (Van Harten and Malysheuski 2016). Assessing potential health impacts is difficult because the number of ISDS cases initiated has increased rapidly in recent years (UNCTAD 2016), and they can take years to resolve. The tobacco industry has mounted several challenges to tobacco control initiatives under ISDS provisions, sometimes backed by the US Chamber of Commerce (Hakim 2015), although so far these have been unsuccessful. It has also been argued that ISDS provisions could be used by pharmaceutical firms to claim compensation for revenues lost when generic versions of patented products are manufactured under a compulsory license, even if all relevant TRIPS and TRIPS-plus provisions have been complied with (Ruse-Khan 2011). Further, ‘regulatory chill’ may be associated with such provisions, which may affect a variety of other regulatory spheres (Friel, Hattersley, and Townsend 2015, 329), such as food, alcohol, and environmental protection. The extent of regulatory chill is difficult to assess because of problems observing the operation of anticipated reaction, but ‘many conflicts between investors and States will never reach the stage of formal arbitration proceedings. Arbitration is a high-risk, high-cost option for both governments and investors. In contrast, the threat of arbitration is cheap and potentially very effective, even in cases where experts might predict that at State would be successful’ (Tienhaara 2011, 627). Unlike many other aspects of globalization, ISDS is contentious even among mainstream economists (Investor-state 2014; Stiglitz 2014; Rodrik 2015).

478   Ted Schrecker

Future Directions and Challenges The preceding discussion has been selective. It has not considered such questions as the long-term impact of the post-2007 financial crisis, the quintessential manifestation of the downside risks of economic integration and their unequal distribution: on health directly; through the macroeconomically misguided policies of selective austerity that have been the predominant response (Stuckler and Basu 2013; Basu, Carney, and Kenworthy 2017), and by ratcheting up economic inequality. It has not addressed the complex challenge of antimicrobial resistance (Laxminarayan et al. 2013), although this seems a natural topic from a political economy perspective because it represents one of the few truly global ‘public bads’ (i.e., avoidance is a global public good) and because the private incentives for contributing practices, such as overuse of antimicrobials in veterinary practice, invite the externalization of costs. It has also dealt only with one dimension of the political economy of non-communicable diseases—the connection with liberalization of trade and investment—despite their clear importance to the global burden of illness and the value of a political economy perspective in addressing both the power dynamics of the corporate contribution to NCDs and the (much less well understood) lack of support through development assistance for NCD-related policies and interventions (Nugent and Feigl 2010). The process by which NCDs became more prominent on the global health policy agenda, and the influences on priority setting within that agenda, invite further investigation from a political economy perspective (Glasgow and Schrecker 2015). This partial list of omissions simply serves to suggest a range of research topics that are likely to yield improved understandings of the role of political and economic structures in producing health and illness (as explicated by Krieger 2011) and the importance of the power asymmetries foregrounded by Ottersen et al. (2014). Here I identify two such lines of inquiry, one primarily empirical and the other primarily normative, although it draws on solid empirical foundations. It is now almost a cliché to assert that divisions between ‘developed’ and developing worlds, the center and the periphery, or the global North and the global South, are shifting and mutating. This is happening in at least two respects. First, as defined by the distribution of economic activity, the world’s center of economic gravity is shifting to the south and east (Dobbs et al. 2012, 16–17), a phenomenon exemplified but only partly captured by the rise of the so-called BRICS countries (Brazil, Russia, India, China, and South Africa) and other blocs of emerging economies (United Nations Development Programme 2013, 43–61) and by the growing number of TNCs headquartered outside the high-income world. Second, and probably with more substantial and immediate consequences for health, economic inequalities within national borders are growing as a consequence of economic integration and (in many cases) neo-liberal domestic policies. Before NAFTA and the WTO regime came into force, journalist Walter Russell Mead (1992, 42) predicted that as a consequence of economic integration, ‘The First and Third

Critical Political Economy of Global Health   479 worlds will not so much disappear as mingle. There will be more people in Mexico and India who live like Americans of the upper-middle class; on the other hand, there will be more—many more—people in the United States who live like the slum dwellers of Mexico City and Calcutta’. At the time, this sounded like hyperbole; now, with 182,000 Indian US dollar millionaires (Stierli et al. 2014) sharing national borders with half a billion people who had no alternative to outdoor defecation circa 2011 (Drèze and Sen 2013), it seems much less so. Less evidence than ever supports the belief that rising tides will lift all boats (Piketty 2014; Bourguignon 2015; among many other recent sources). Robinson has described the corollary imperative for studies of development to transition ‘from a territorial to a social cartography’ (Robinson 2002) and indeed has argued that as a consequence of globalization ‘a sociology of national development is simply no longer a tenable undertaking’ (1061). Rather, development must be understood with reference not to territorial boundaries and national policies but to  the map of ‘new globalized circuits’ of production and capital accumulation (Robinson 2002, 1060). Mead’s prediction about living standards may prove to be true of health as well, with ‘health divides’ within countries and even smaller jurisdictions resembling those between rich and poor countries; in the small deindustrialized city in the north of England where I live and work, the difference in male life expectancy between the high deprivation town center ward and suburban wards a few miles away is larger than the difference in national average male life expectancy between the United Kingdom and Tanzania (World Bank 2016; Public Health England 2016). Under these circumstances, it may be necessary to rethink what constitutes a ‘global’ health issue. More concretely, over the longer term one of the most important dynamics in GPEH may be the way glob­al­i­za­tion alters the distribution of income, wealth, and economic opportunity within national borders—and thereby affects the political allegiances that influence domestic policy choices relevant to health and health inequalities. For example, with roughly 70 percent of the world’s poorest people no longer living in the world’s poorest countries, one observer now argues that ‘this will likely pave the way for addressing poverty reduction as primarily a domestic issue rather than primarily an aid and international issue; and thus a (re)framing of poverty as a matter of national distribution and national social contracts and political settlements between elites, middle classes and the poor’ (Sumner 2012, 3). But will the consequences involve reduced or increased economic and health inequalities? This and related questions are explored in a companion chapter (Schrecker, this volume). Some of the most significant bodies of evidence for a GPEH have been generated by anthropologists and physician-anthropologists. This is perhaps because of anthropology’s distinctive ability to connect macro-scale processes, which are the major concern of international relations and international political economy, with their local consequences through longer-term, place-specific fieldwork (ethnography), adding texture and explanatory power that cannot be provided by the quantitative metrics of epidemiology (Farmer 1996, 262–263; Nguyen 2012). In this vein, the most important analytical contribution of anthropologists may be the concept of ‘everyday violence’ (Scheper-Hughes

480   Ted Schrecker 1993) or structural violence (Rylko-Bauer and Farmer 2016), the latter a term coined by Johan Galtung but most closely associated with physician/anthropologist Paul Farmer. Writing about his experience practicing medicine in Haiti, and to the connections among the deprivation associated with its ‘unimaginable poverty’, the country’s colonial history, and more recent decisions by the US government and the Inter-American Development Bank, Farmer argues that ‘[s]tructural violence is the natural expression of a political and economic order’ that ‘has long been global, or almost so, in its reach’ (Farmer 2004, 311, 317). At least two core ideas operate here. First, global health politics must be understood with the recognition that suffering can be inflicted and lives destroyed by remote control: by choices made half a world away, by people and within institutions that have no contact with those affected and are in no way accountable to them. A contemporary analogy involves drone strikes, the epitome of military violence operating at a distance. The effects of such faraway policy choices are, in this line of argument, as destructive and reprehensible as if they were inflicted at close quarters. Second, such effects can operate through social or institutional structures (broadly defined) that obscure or diffuse individual responsibility but are nevertheless the result of past authoritative choices. ‘Structural violence is violence that is exerted systematically—that is, indirectly—by everyone who belongs to a certain social order’ (Farmer 2004, 307). These two ideas combined illuminate (for example) the political economy of structural adjustment policies discussed previously in this chapter. From this perspective, social and spatial distance are not viewed as diminishing responsibility, just as the responsibility of the drone operator and her superiors is not diminished by distance from the target. Direct parallels exist with philosopher Thomas Pogge’s long-standing argument from the negative duty to avoid causing harm and the way in which economic institutions routinely fail to respect that duty (Pogge 2007). ‘By avoidably producing severe poverty,’ he writes, ‘economic institutions substantially contribute to the incidence of many medical conditions. Persons materially involved in upholding such economic institutions are then materially involved in the causation of such medical conditions’ (Pogge 2004, 137). For Pogge, moral responsibility for harms like those associated with extreme poverty follows causal responsibility across national borders, subject only to the proviso that plausible alternative sets of institutions that would be more conducive to reducing or eliminating poverty must exist. As illustrated by the alternative prescription for ‘adjustment with a human face’ or, more generally, by ‘social democratic counterfactuals’ to neo-liberalism (Huber and Solt 2004), this test is not difficult to meet unless one simply defines plausibility in terms of congruence with the interests of the powerful. Nancy Scheper-Hughes (1995) has championed a ‘militant anthropology’ that directly challenges the unaccountably powerful on ethical grounds. That militant engagement can and should be transferred to the social science of health more generally.

Note 1. Full disclosure: coordinated by the author.

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pa rt I V

IS SU E S I N GL OBA L H E A LT H P OL I T IC S

chapter 25

The H um a n R ight to Hea lth a n d Gl oba l Hea lth Politics Gorik Ooms and Rachel Hammonds

Until the 1990s much of the scholarly debate in international relations was defined by ‘realism’, which assumes that states are self-interested and therefore most often behave in ways that predominantly preserve or promote their own interests. The ‘intellectual hegemony’ of realism ‘was the perspective against which new ideas had to be tested’ (Katzenstein, Keohane, and Krasner 1999, 18). It not only dominated research on security and trade, but also influenced research on international cooperation: ‘[t]heories of international cooperation . . . made a big leap forward by accepting the assumption that states are self-interested and have conflicts of interest with one another’ (Martin 1999, 52). Since the 1990s ‘constructivism’ has challenged realism’s dominance, as both a critique and a complementary school of thought. In defining constructivism as complementary to realism, constructivists consider norms, values, ideas, and other ‘social constructs’ to be interests of a different kind. As Wendt (1999, 242) notes, ‘[t]he vast majority of states today see themselves as part of a “society of states” whose norms they adhere to not because of on-going self-interested calculations that it is good for them as individual states, but because they have internalized and identify with them’. Thus for constructivists, states comply with international norms because these norms represent a kind of interest, even if compliance may require that they sacrifice some of their other interests. Realism does not rule out cooperation between states intended to address transborder issues, like health problems. On the contrary, the simple fact that viruses do not respect state borders creates a solid ground for ‘international cooperation in the national interest’ (International Task Force on Global Public Goods 2006). Global health politics, from a realist perspective, is likely to be informed by the interests of states with the power and money to influence global health politics and therefore is likely to focus on cross-border issues that affect these states, such as the spread of infectious diseases. A constructivist perspective allows one to understand why global health politics may go beyond ‘international cooperation in the national interest’ and addresses global

494   Gorik Ooms and Rachel Hammonds health inequalities unrelated to infectious disease. From a constructivist perspective, the most likely candidate for a norm that states may want to comply with, because they value the norm itself, is the human right to health, as enshrined in the International Covenant on Economic, Social and Cultural Rights (ICESCR), the Convention on the Rights of the Child, and other international human rights law treaties. Other norms, like the Millennium Development Goals (MDGs) and their successors, the sustainable development goals (SDGs), may play a similar role. From an international law perspective, they do not have the same authoritative value as a legally binding treaty, but they may have more political value and therefore more influence on global health politics. The influence of the human right to health on global health politics can be explored from numerous angles. We focus in this chapter on two distinct approaches, the normative and the descriptive, each of which answers different types of questions. The normative approach employs right to health norms to depict what governments (and other actors) ought to do so as to describe how global health politics would look if the right to health drove politics. The descriptive approach examines the reality of global health politics to understand why global health’s ‘politicians’ do what they do, to determine the extent to which global health politics is influenced by the right to health. Combining both approaches is more illuminating. A strictly normative approach would lead to a description of an ideal type of global health politics that bears little resemblance to the present reality. Furthermore, it would contain many lacunae, as the human right to health is essentially a principle that requires further crystallization through application in real life, as explained below. A strictly descriptive approach would be difficult; if we do not know what right to health compliant global health politics should look like, we cannot judge whether the world is moving toward it (or not). Combining both approaches requires a note of caution. While both the normative and descriptive approaches can illuminate the same topic, they belong to different ­epistemological dimensions. They look for, or claim, distinct kinds of truths. These statements—(a) because of the law, cars on this highway should not drive faster than 120 kilometers per hour (kmh) and (b) cars on this highway are not driving faster than 120 kmh because of the law—may look very similar but are quite different. Statement (a) can be true, even if all cars are driving much faster than 120 kmh. This is because it is a normative statement, which can be true even if the empirical reality seems to tell a different story. Furthermore, even if all cars drive at 120 kmh or slower, statement (b) could still be untrue. For example, drivers may not care about the law, but respect the speed limit out of fear that faster driving could damage their cars. Thus, even when we observe global health politics that is in line with the right to health, it does not necessarily mean that it is in line with the right to health because of the right to health. We therefore divide this chapter into two sections. The normative section briefly explores what global health politics should do to be compliant with the right to health, then discusses three main obstacles to greater compliance. First, we examine the post– World War II evolution of human rights, from citizens’ rights to human rights. Second, we explore the legacy of the historical cleavage of human rights into two international treaties, the ICESCR, often characterized as costly entitlements, and the International

Human Right to Health   495 Covenant on Civil and Political Rights (ICCPR), often erroneously classified as cost-free freedoms. Third, we introduce the idea of human rights as a lever, not a force. The lack of ‘systematic evidence to suggest that ratification of human rights treaties in the UN system itself improves human rights practices’, in combination with the finding that ‘the growing legitimacy of human rights ideas in international society . . . provides much leverage for nongovernmental actors to pressure rights-violating governments to change their behavior’ (Hafner-Burton and Tsutsui 2005, 1401), indicates that compliance by states should only be expected if civil society holds states accountable. The descriptive section explores how the human right to health has informed, and is informing, global health politics. The most often cited example of the right to health’s influence on global health politics is the AIDS response (McInnes and Lee 2012). We use this case to explore, and tentatively confirm, the idea of human rights as a lever, then explain how civil society uses the right to health to formulate specific claims and to press the international community into honoring these claims. We then revisit recent history to explore why the World Health Organization’s (WHO’s) Health for All by the Year 2000 strategy (WHO 1981), which was also explicitly grounded in the human right to health, did not influence global health politics in the way it should have (for the strategy to succeed). Finally, we turn to the new WHO strategy of universal health coverage (UHC), again—but less explicitly—grounded in the human right to health, and explore what it would take to influence global health politics in a right to health compliant manner.

The Normative Approach to Health as a Human Right From Citizens’ Rights to Human Rights While it is now taken for granted that ‘[h]uman rights are rights held by individuals simply because they are part of the human species’ (Ishay 2008, 3), this was not self-evident when the expression ‘human rights’ gained currency. The French Declaration of the Rights of Man and of the Citizen of 1789 was, as the title suggests, a declaration about the rights of (some) French citizens. It was a product of the French Revolution of 1789, and ‘in 1791, the French revolutionary government granted equal rights to Jews; in 1792, even men without property were enfranchised; and in 1794, the French government officially abolished slavery’ (Hunt 2007, 28). Women were not enfranchised because they were not considered full-fledged citizens. The French National Assembly also made a distinction between ‘active’ and ‘passive’ citizens. Women, servants, and foreigners were passive citizens; they did not have the same rights as ‘active’ citizens. Furthermore, the French did not take it upon themselves to spread human rights to the inhabitants of other countries. The 1776 US Declaration of Independence may well have mentioned that ‘all Men are created equal, that they are endowed by their Creator with certain unalienable

496   Gorik Ooms and Rachel Hammonds Rights, that among these are Life, Liberty, and the pursuit of Happiness’, but many of the signatories saw no contradiction in being slaveholders. Both documents were declarations of the rights of citizens of given countries, and the corresponding duties rested upon the governments of these countries. These were not human rights declarations. The world wars during the twentieth century, and World War II in particular, forced a revision of the concept. If human rights were only citizens’ rights, then the rights of German citizens under Nazi rule may have been only those rights recognized by Hitler’s government. This was untenable. The 1948 Universal Declaration of Human Rights (UDHR) refers to the atrocities of World War II and proclaims the human rights of ‘all human beings’ (article 1), ‘everyone’ (articles 2, 3, 6, etc.), and ‘all’ (article 7). Thus, the UDHR seems to leave little ambiguity about the nature of the rights it proclaims: that is, human rights, not citizens’ right. However, some ambiguity remains because of the way the corresponding duties are allocated in the UDHR. On duties, the UDHR remains ambiguous. On the one hand, it seems to place the corresponding duties upon humanity: ‘Member States have pledged themselves to achieve, in co-operation with the United Nations, the promotion of universal respect for and observance of human rights and fundamental freedoms’. On the other hand, the UDHR calls itself ‘a common standard of achievement for all peoples and all nations’. Thus, the duties seem to remain with states, or more precisely, ‘all peoples and all nations’. Does the ambiguity about corresponding duties affect the nature of the rights of humans or citizens? Much has been written about the relationship between rights and duties. To briefly summarize, some scholars argue that a human right only qualifies as such if it is enforceable; it is ‘essential to the existence of a set of “rights” that there be some specifiable, and more or less effective, mechanism for enforcing them’ (Geuss 2001, 143). If this is so, then being held as a slave was not a human rights violation as long as some states tolerated or promoted slavery (and other states did not intervene); the essence of the right to freedom sprang into existence when all states agreed to abolish slavery. Other scholars argue that human rights only qualify as such when they are at least claimable, when the duty bearers and the content of the duty can be identified (O’Neill 1996). Whether the duty bearers do live up to their duties is a different matter; what matters is that they should: that is enough for rights owners to have a legitimate claim. Some scholars agree with this ‘claimability’ condition but defend a softer version of it: it is not essential that the duty bearers can be clearly identified or that the extent of their duties is clearly defined; what matters is that duty bearers are identifiable in theory, if not in practice (Griffin 2008). If the links between duty bearers and duties are not clear, it only means that more work needs to be done to clarify them. However, it is essential that some people or institutions, somewhere on the earth, are able to fulfill the corresponding duties. We side with the soft version of the claimability condition: a human right can only be a human right if it is possible, at least in principle, to identify people and institutions who can, together, ensure that right to all human beings. If no institution or collective of institutions is able to ensure a given right to all humans, the claim is void. If it is possible to imagine how institutions could ensure a given right to all humans, the claim has

Human Right to Health   497 substance. Of course it is a problem if the corresponding duty bearers have not been identified (yet), but the claim makes sense and requires identifying duty bearers. We argue that it would be more problematic if the duty bearers were being identified in such a way that the best imaginable version of the enjoyment of the human right is either meaningless or very different for different human beings. Unfortunately that is exactly what happened when the UDHR was translated into legally binding treaties. The UDHR is a declaration, not a treaty; it had to be ‘translated’, and further elaborated, into a treaty. Furthermore, the UDHR contains two different kinds of rights: ‘freedoms’ and ‘entitlements’. Freedoms are claims to non-interference in some important aspects of a person’s private life: going where one wants to go, thinking what one wants to think, and believing what one wants to believe. Entitlements are claims to active support, when needed, for a person to subsist in dignity: the provision of water, food, housing, education, healthcare, and so forth. Political and ideological disagreement over the role of the state in providing for human rights leads to a division in the international community. Two international covenants (treaties) were elaborated, one on civil and political rights (freedoms), the other on economic, social, and cultural rights (entitlements). This division became one of the ideological battlegrounds of the Cold War: the ICCPR became ‘the human rights treaty of the West’, while the ICESCR became ‘the human rights treaty of the Eastern Bloc’. Even if most Western states ratified both the ICCPR and the ICESCR, they only took the freedoms seriously (as human rights): freedom of political opinion, freedom of press, freedom of religion, and freedom from arbitrary arrest. The most famous non-governmental organizations (NGOs) in human rights were (and to a large extent still are) focused on freedoms. Both the ICCPR and the ICESCR identify duty bearers more clearly than the UDHR does. One may argue that they are treaties more about duties than rights, with both the ICCPR and the ICESCR identifying states as primary duty bearers. Article 2(1) of the ICCPR proclaims: ‘Each State Party to the present Covenant undertakes to respect and to ensure to all individuals within its territory and subject to its jurisdiction the rights recognized in the present Covenant’. Therefore, the content of the human rights freedoms of a given person is limited by the ability of her or his state. In theory, this does not affect the substance of the human rights mentioned in the ICCPR; as freedoms, they are supposed to be cost free, requiring non-interference by the state. Even the poorest state can allow its citizens and residents to freely express their opinion. In reality, the capacity of states does make a difference; a fair and effective police force and judicial system require significant resources. Furthermore, realizing human rights depends not only on capacity but also on the willingness of duty bearers. Considering how World War II inspired the UDHR, it does not seem plausible that Hitler’s government organized the Holocaust because of the lack of ability to respect human rights (or because there was no UDHR or other legal text clarifying the content of human rights). The Holocaust was the result of an unwillingness to ensure human rights, an intentional exclusion of specific groups of people from citizenry. As explained previously, the weak version of the claimability condition holds that a human right does not have to be enforceable to be a human right; a legitimate

498   Gorik Ooms and Rachel Hammonds claim is sufficient, as long as it is possible, at least in principle, to identify people and institutions that can ensure that right to all human beings. One may thus argue that as long as a state can be identified as a duty bearer—one that is able, even if unwilling—the human right has substance. Considering history, however, we argue that the claimability condition also requires that solutions be available to address the consequences of manifestly unwilling states, simply because manifestly unwilling states are a reality. The ICCPR does not address the problem of unable or unwilling states. Thus, while the list of human rights mentioned in the ICCPR may be the same for all human beings, the substance of these rights differs depending on the country one lives in. We argue that the rights proclaimed in the ICCPR are somewhere between citizens’ rights and human rights: they are rights one has, partly by virtue of being a citizen of a given state, partly by virtue of being a human being. Article 2(1) of the ICESCR proclaims: ‘Each State Party to the present Covenant undertakes to take steps, individually and through international assistance and co-operation, especially economic and technical, to the maximum of its available ­ resources, with a view to achieving progressively the full realization of the rights recognized in the present Covenant.’ Like Article 2(1) of the ICCPR, article 2(1) of the ICESCR also locates the corresponding duties with states, but it contains two qualifiers. First, the corresponding duty is to take steps, to the maximum of a state’s available resources, which means explicitly that the substance of the human rights proclaimed under the ICESCR differs between humans, depending on the state they live in. (For example, if you have cancer and you happen to live in a country that is wealthy enough to provide cancer treatment to all citizens who need it, your right to health includes cancer treatment. But if you happen to live in a country that is too poor to provide cancer treatment, your right to health does not include a legitimate claim to cancer treatment.) Thus the ICESCR is quite explicitly a treaty about citizens’ rights. However, the second qualifier mitigates that and turns the ICESCR into a treaty about rights that are somewhere in between citizens’ and human rights: states must take steps, individually and through international assistance. (If you have cancer and live in a country that is unable to provide cancer treatment to everyone who needs it, you may be tempted to use the ICESCR as the basis of a claim upon the international community.) Thus the ICESCR seems to confirm and codify duties across state borders. However, the precise nature and scope of these duties remains undefined, and the international obligation to provide assistance became one of the most controversial issues in human rights scholarship. Rather than embarking on an overview of all the opinions and positions, it is more instructive to cite concluding remarks formulated by Tobin (2012, 368), who explored the issue in relation to the right to health: The meaning of the international obligation to co-operate for the purpose of realizing the right to health is far from settled. But its ambiguity and contested nature, especially in the context of international assistance, are not sufficient grounds to relegate this obligation to the periphery in any discussions concerning the right to health. On the contrary it must occupy a more central place given that co-operation

Human Right to Health   499 between states is critical to ensuring the effective enjoyment of the right to health. The challenge, however, is to provide a persuasive interpretation that can outline the ‘concrete measures’ required for its effective implementation.

In conclusion, while the UDHR advanced toward human rights (and away from citizens’ rights), the ICCPR was a step toward citizens’ rights, and the ICESCR did not represent a step toward or away from human rights. In practice, the benefits of human rights remain a kind of ‘passport lottery’; not only the enjoyment of human rights, but even the substance of the claims, remains to a large extent defined by the willingness and the ability of states to provide for them. The advent of the ICCPR and ICESCR has coincided with human rights playing an increasingly important role in international relations and diplomacy. Given the preference of wealthier Western countries (and the United States in particular) for ICCPR rights, the role of human rights in international politics has mainly been limited to freedoms. For example, Forsythe’s (2006) descriptive book Human Rights in International Relations is almost exclusively focused on human rights freedoms. Other scholars have written about the role of ‘subsistence rights’ in international relations—that is, human rights entitlements, reduced to their minimum essence—but these books are normative, describing the role human rights (entitlements) should have in global politics, not the role they actually played (Shue 1996; Vincent 1986). Even if focused on freedoms, the attention given to human rights in international politics remained limited. The wealthier and most powerful states showed little hesitation in dealing and trading with states (and heads of states) that were notorious human rights (freedoms) violators; such were ‘the politics of liberalism in a realist world’ (Forsythe 2006, 251). In the 1990s, however, the genocides in Rwanda and then in the former Yugoslavia shook the international human rights regime as the Holocaust had previously done. Although the Convention on the Prevention and Punishment of the Crime of Genocide, which has clearer international duties, could have applied to these extreme cases of state unwillingness to respect human rights, they highlighted the shortcomings of the existing state-centered human rights regime. When there were doubts about whether a situation qualified as genocide, international human rights law provided little guidance on how the international community should act. These events, together with others, led to the birth of the ‘Responsibility to Protect’ doctrine, which addresses the boundaries of states’ collective responsibility to prevent extreme human rights violations. Whether the Responsibility to Protect will gain the status of a new international legal norm or remain political rhetoric is yet to be determined. As Stahn (2007, 120) concludes, ‘[r]esponsibility to protect is thus in many ways still a political catchword rather than a legal norm. Further fine-tuning and commitment by states will be required for it to develop into an organizing principle for international society.’ Moreover, it does not encompass all human rights, only a limited number of extreme human rights violations, including genocide, war crimes, ethnic cleansing, and crimes against humanity. But it has the merit of highlighting the shortcomings of the state-centeredness of the present human rights regime.

500   Gorik Ooms and Rachel Hammonds With regard to health, it is important to note that at the beginning of the twenty-first century the international community implicitly (not explicitly) accepted collective responsibility for the provision of antiretroviral (ARV) medicines for people living with AIDS in low- and middle-income countries. If wealthier states did not explicitly acknowledge their status as duty bearers across state borders, they certainly behaved as such. We explore this further below. The main point is that if one takes the approach of a constructivist and looks at the right to health as a norm that may have guided global health politics so far, or that may provide guidance for global health politics in the future, looking beyond the ‘face value’ of the human right to health may be somewhat disappointing. This is because international human rights law addresses mainly how states ought to behave at the domestic level. However, by taking a historical perspective, ranging from the eighteenth-century American and French declarations to the 1948 UDHR, 1966 ICCPR, and ICESCR and continuing to present-day state behavior in response to domestic human rights issues, there is some evidence of a gradual shift from an idea of rights that people have by virtue of being citizens to an idea of rights that people have by virtue of belonging to the human species. This is not much, but it is something to build on.

Freedoms versus Entitlements: Implications for Global Health Politics For many global health scholars, stating that health is a human right makes little sense. It sounds as though all humans have an entitlement to be healthy, and that is like saying that all human beings have an entitlement to be happy. However, like other human rights, the right to health is a kind of shorthand. It is not a right to be healthy but a legitimate claim to a basket of freedoms and entitlements that can have a positive impact on one’s health. For example: both the entitlement to healthcare and the freedom to criticize the government for not providing adequate healthcare can have a positive impact on one’s health. We explained previously that the difference between human rights freedoms and entitlements was a key reason for the elaboration of two different covenants: the ICCPR and the ICESCR. This division has been criticized by many human rights scholars as artificial and misleading. However, while we prefer more sophisticated typologies that reveal the intellectual kinship of all human rights—such as those suggested by Shue (1996) and Eide (2001)—not only has the division resulted in different treaties, entailing different legal obligations, it is also rooted in reality. If all human rights are legitimate claims to mixed baskets of entitlements and freedoms, and no human rights consist of only claims to freedoms or only claims to entitlements, it is clear that in some human rights baskets one will find more freedoms than entitlements, and vice versa. Freedom of speech, for example, does require an entitlement to protection against retaliation by those who do not want certain opinions to be voiced—a journalist who wants to write

Human Right to Health   501 about crime syndicates needs active protection from the state to have real freedom of expression—but it mostly requires freedoms: non-interference whenever one wants to express an opinion. The right to health, for example, does require the freedom to criticize a health authority not doing what it should do, but it mostly requires entitlements to positive efforts. And this difference—somewhat artificial and somewhat real—has consequences when it comes to exploring international duties. According to Shue (1996, 19), human rights ‘are everyone’s minimum reasonable demand upon the rest of humanity’. Even so, we cannot ignore the existence of a world order based on states, and neither did Shue; in his view, states continue to bear the primary duty to ensure the enjoyment of human rights for their citizens, and only if a state fails to do so must ‘some other agent at least sometimes . . . step in’. When it comes to violations of human rights freedoms—presumed to require only non-interference—the concerned state is probably unwilling to do what it should do, because doing what it should do would cost nothing. It is then relatively easy for other states to point a finger at the concerned state and thus to deny their responsibility. When it comes to violations of human rights entitlements, such as not providing appropriate healthcare, the concerned state will often be unable to do what it ought to do, which makes it a much more difficult for other states to reject their secondary duty. We now know the financial costs of considering access to ARV treatment a universal entitlement—financed with domestic resources where possible, by the international community in countries that cannot afford it—and that gives us an idea of the potential claims if other health issues were to be treated similarly. Therefore, wealthier states are understandably reluctant to accept the principle that human rights ‘are everyone’s minimum reasonable demand upon the rest of humanity’ (Shue 1996, 19), as it would open a seemingly bottomless pit.

The Human Right to Health as a Lever, Not a Force The third important obstacle to using the human right to health as guidance for global health politics is the finding that ratification of human rights treaties does not in itself improve human rights practices, in combination with the finding that human rights ‘provide leverage for nongovernmental actors to pressure rights-violating governments to change their behavior’ (Hafner-Burton and Tsutsui 2005, 1401). In this case, the ‘non-compliant governments’ would be the ones that have most influence on global health politics. Canada, France, Germany, Japan, Norway, the United Kingdom, and the United States make the biggest financial contributions to global health (Institute for Health Metrics and Evaluation 2017), and we assume here that they are thus the most influential in global health politics. At the domestic level, these states have a generally positive human rights record, which may make us believe that they are, a priori, proponents of all human rights, including the right to health. Decades of social struggle in the nineteenth and twentieth centuries (continuing into the twenty-first century in the United States) expanded access to social rights at the domestic level.

502   Gorik Ooms and Rachel Hammonds However, when it comes to compliance at the global level, we cannot take for granted the commitment to human rights of these states. First, while Canada, France, Germany, Japan, Norway, and the United Kingdom have ratified the ICESCR, the United States has not. Second, as discussed previously, the shift from citizens’ rights to human rights has only recently begun and is far from complete. As Tobin (2012, 340) notes, several states have argued that ‘although the need for international co-operation and assistance reflected an “important moral obligation”, it was “not a legal entitlement”.’ Third, all these states have interests that may be at odds with global health politics aligned with the right to health: to avoid being obliged to pay for healthcare for other states’ citizens, but also, for example, to continue recruiting health workers from countries where they are needed more, without being labeled a human rights violator. Therefore, we should not expect these states to live up to their international duties unless non-governmental actors pressure them into it. If the substance of the human right to health remains somewhat vague; if, a fortiori, the substance of the international duties for the realization of the right to health remain vague; and if on top of that, we can only expect states to act upon their international duties if NGOs use the right to health as a lever for their claims, then the role of NGOs in advancing the right to health is more than a strategic one. It becomes a defining one. The successful right to health claims advanced by NGOs upon the global health politics of influential states are not only contributing to the realization of the human right to health, they are also defining the substance of the right to health. For example, before HIV/AIDS activism claimed that access to ARVs is an essential element of the right to health, before UNAIDS and the Office of the High Commissioner on Human Rights (OHCHR) confirmed this claim in 2002 (UNAIDS and OHCHR 2006), before ARVs were added to WHO’s essential medicines list (also in 2002, and under HIV/AIDS activist pressure) (Laing et al. 2003), and before the creation of a mechanism that allowed the practical international cooperation required (again in 2002, i.e., the Global Fund), few lawyers would have unequivocally confirmed that access to ARVs is an essential and universal element of the right to health. Since then access to ARV therapy has been cited as a textbook example of the right to health (Wolff 2012; Tobin 2012; Griffin 2008; Chapman 2016). We therefore agree with Tobin (2012, 368) when he argues that ‘[t]he meaning of the international obligation to co-operate for the purpose of realizing the right to health is far from settled’, and that the challenge remains ‘to provide a persuasive interpretation that can outline the “concrete measures” required for its effective implementation’. This is a challenge not only for legal scholars but also for global health scholars and NGOs. While we would have liked to end this normative section with a clear and detailed overview of what states ought to do in global health politics to support the human right to health, that is not possible. The 2000 General Comment (United Nations International Committee on Economic, Social and Cultural Rights 2000) contributed greatly to clarifying the contours of the right to health; however, it leaves many important issues unsettled (Forman et al. 2013). As Chapman (2016) argues, the human right to health is an emergent human right; it has not fully crystallized yet, and that is particularly true for its international dimension.

Human Right to Health   503

The Descriptive Approach to Health as a Human Right HIV/AIDS, the Right to Health, and Global Health Politics When global health and human rights are mentioned together in a single sentence, one can usually expect HIV/AIDS to be mentioned in the next. Indeed, the global HIV/ AIDS response has been the ‘poster child’ of health and human rights advocates and is often mentioned as the example that other health issues (and their advocates) should follow (Forman et al. 2012). The relationship between HIV/AIDS and human rights was forged at a time when very little was known about HIV/AIDS prevalence outside of the United States, when most of the affected people faced stigmatization and discrimination because of their sexual orientation or profession, and when there was no treatment, all of which contributed to healthcare professionals’ reluctance to treat them with dignity. Human rights were invoked, first to shield people living with HIV/AIDS from discrimination and later as an essential element of prevention strategies (Mann 1999). Within less than a decade HIV/AIDS activism evolved into a global struggle, with the human right to health at its center. The first cases of what later became known as acquired immunodeficiency syndrome (AIDS) were described in a paper in June 1981, the patients being five white homosexual men (Piot 2015). Three years later, Piot et al. published their paper on AIDS among heterosexual men and women in Zaire (now Democratic Republic of Congo) in the Lancet (Piot et al. 1984). Five years after that, ACT-UP New York and AIDS Action Now issued the ‘Montreal Manifesto’ at the Fifth International AIDS conference in June 1989, which demanded an international code of rights for people with HIV, an international development fund to help poor countries to meet their health responsibilities, and ‘the conversion of military spending worldwide to medical health and basic social services’ (Brier 2009, 156). The Global Fund to fight AIDS, Tuberculosis and Malaria (Global Fund) was created twelve years later. The discovery of ARV medicines may have led to a temporary decline in HIV/AIDS activism in the United States, but not for long. Although several chapters of ACT-UP closed, ACT-UP Philadelphia reached out to HIV/AIDS activists in sub-Saharan Africa: ‘The emerging new core of ACT UP Philadelphia found members of the city’s large black community to be particularly receptive to their message about fighting AIDS in Africa, both because of feelings of ethnic solidarity as well as bonds of personal experience’ (Smith and Siplon 2006, 61). One of the first issues on the agenda of the emerging global HIV/AIDS activism network was the World Trade Organization’s (WTO) Trade-Related Aspects of Intellectual Property Rights (TRIPS) Agreement. TRIPS was an annex to the Final Act of the Uruguay Round of Multilateral Trade Negotiations, which also included the 1994

504   Gorik Ooms and Rachel Hammonds Agreement Establishing the World Trade Organization (Gervais 2012). Thus, TRIPS was part of a package deal, a part strongly promoted by many industrialized countries and reluctantly accepted by most low-income countries, as a price to be paid for WTO membership (Correa 2000). The agreement obliged WTO members to adopt minimum standards for intellectual property protection. This in turn had a direct effect on the cost of ARV medicines. In the words of Stiglitz (2008, 181), ‘when the trade ministers signed the trade agreement in Marrakech in April 1994, they were in effect signing the death warrants for thousands of people in Africa and other developing countries’. The TRIPS agreement included some flexibilities, including the possibility for governments to issue ‘compulsory licenses’ and thus to allow manufacturers of medicines to produce generic (and much cheaper) copies of patent-protected medicines, without the patent owner’s permission. Brazil used this flexibility as part of its strategy to provide free ARV treatment (Galvão 2005). South Africa adopted the South African Medicines and Medical Regulatory Devices Act in 1998, which allowed a systematic use of TRIPS flexibilities. A coalition of pharmaceutical companies sued the government of South Africa. Activists from all over the world mobilized against the pharmaceutical companies. In April 2001 the coalition of pharmaceutical companies withdrew its lawsuit (Brier 2009). According to Barnard (2002, 167), the framing of the lawsuit’s withdrawal as a victory of ‘the requirements of justice and respect for human rights’ was ‘seriously misleading’, because most countries in Africa were too poor to provide ARV treatment even at reduced costs. But global HIV/AIDS activism did not stop with the end of the lawsuit. In the same month Harvard University faculty members issued the ‘Consensus Statement on Antiretroviral Treatment for AIDS in Poor Countries’. ‘As individuals committed to equitable access to health care for all peoples and to human rights’, the statement acknowledged that ‘AIDS treatment will always be more expensive than poor countries can afford, meaning that international aid is key to financing the effort’ (Individual Members of the Faculty of Harvard University 2001). It called for a global fund to help developing countries finance AIDS treatment. Echoing the 1989 Montreal Manifesto, this became the next target of global HIV/AIDS activism. When the Global Fund was finally up and running in 2002, allowing the rollout of a global AIDS treatment effort, helped by the President’s Emergency Plan for AIDS Relief (PEPFAR), HIV/AIDS activism successfully challenged the practice of making patients pay ‘user fees’ (Souteyrand et al. 2008) and the imposition of expenditure ceilings by the World Bank and the International Monetary Fund (Rowden 2013; Baker 2010). Did AIDS activism ‘create’ a new and universal right to health entitlement? That would be at odds with the concept of human rights: ‘rights held by individuals simply because they are part of the human species’ (Ishay 2008) and therefore not dependent on the willingness (or not) of states to ensure their enjoyment. In our opinion, AIDS activism ‘clarified’ one element of the right to health, helping one element of the right to health to ‘emerge’ from the ambiguities and weaknesses of the international treaties’ texts. Other elements are waiting to be ushered in.

Human Right to Health   505

Health for All, the Right to Health, and Global Health Politics A few years before the first cases of HIV/AIDS were described in the medical literature, the International Conference on Primary Health Care took place in September 1978. The Declaration of Alma Ata (International Conference on Primary Health Care 1978), which informed the WHO Health for All by the Year 2000 strategy (WHO 1981), starts with an explicit reference to the human right to health: ‘The Conference strongly reaffirms that health . . . is a fundamental human right’. Yet most global health scholars would probably agree more with the statement that global health politics derailed the health for all strategy (Solar and Irwin 2006) than with the statement that the health for all strategy had a deep impact on global health politics. How did the former occur, and what should global health politics have done to enable the strategy? If, in line with the human rights as a lever idea, we look for the claims made by NGOs in Canada, France, Germany, Japan, Norway, the United Kingdom, and the United States in the name of right to health, for their governments to enable the health for all strategy, the first challenge is to identify these NGOs. While there are many references to the Alma Ata ‘movement’ (Packard 2016; Birn, Pillay, and Holt 2017), the movement was composed predominantly of civil servants, academics, and WHO and UNICEF staff. The Alma Ata equivalents of ACT-UP and Health GAP did not exist. The People’s Health Movement (PHM) was born in 2000, twenty-two years after the declaration. When we scan the Declaration of Alma Ata itself for what the governments of Canada, France, Germany, Japan, Norway, the United Kingdom, and the United States should have done, we can find many vague references to international cooperation, such as ‘urgent action by all governments, all health and development workers, and the world community’; ‘a most important world-wide social goal’; and ‘social target of governments, international organizations and the whole world community in the coming decades’ (International Conference on Primary Health Care 1978). The comment that a ‘genuine policy of independence, peace, détente and disarmament could and should release additional resources’ comes close to ‘the conversion of military spending worldwide to medical health and basic social services’, demanded in the Montreal Manifesto (Brier 2009). Yet it was somewhat contradicted by the statement that primary healthcare (PHC) should be provided ‘at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination’ (International Conference on Primary Health Care 1978). A global fund, as demanded in the Montreal Manifesto, would have undermined that spirit of self-reliance. Those who wrote the Declaration of Alma Ata were aware that PHC would cost more than many countries could afford. The proposed solution was not a global fund for PHC, but a call for ‘[e]conomic and social development, based on a New International Economic Order [NIEO]’, as being ‘of basic importance to the fullest attainment of health for all and to the reduction of the gap between the health status of the developing and developed countries’ (International Conference on Primary Health Care 1978). The NIEO

506   Gorik Ooms and Rachel Hammonds was a ‘two-pronged program—aimed at securing an equitable distribution of the world’s resources and meeting the minimum needs of the poorest people all over the world’ (Singh 1977, 109). Each claim made as part of the NIEO could have been claimed as an international duty to realize the human right to health, and perhaps the mention of the NIEO in the Declaration of Alma Ata should be perceived as such. The NIEO agenda attracted broad support from NGOs in powerful states, notably in the United Kingdom (O’Sullivan 2015). By the time of the Declaration of Alma Ata, however, the ‘narrow and specific window of geopolitical opportunity’ for the NIEO was already closing (Gilman 2015, 1). In 1979 Walsh and Warren proposed replacing PHC with selective PHC, as an ‘interim strategy’. Their argument was that too many countries were unable to afford PHC as set out in the Declaration of Alma Ata (Walsh and Warren 1979). UNICEF, WHO’s main partner in supporting PHC, soon embraced selective PHC, with resource scarcity as the main rationale. According to Packard (2016), Executive Director James Grant of UNICEF was a ‘surprising’ advocate of selective PHC considering his earlier career and statements. However, ‘Grant was impatient. He refused to sit by and watch millions of children die from preventable deaths while the world built effective primary health-care systems’ (Packard 2016, 257). Thus, if we examine the health for all strategy for concrete measures claimed by NGOs based in powerful states and articulated in the name of the human right to health, we find few. The claim that comes closest to what HIV/AIDS activists claimed is the NIEO, but it is difficult to call that a concrete measure. Nevertheless, it would be an exaggeration to attribute the failure of the Alma Ata movement—in terms of influencing global health politics—to this reason alone. In 1978 the Cold War continued to influence human rights discourse, whereas HIV/AIDS activists arguably benefitted from the optimism of the post–Cold War period. While the global HIV/AIDS response started against the backdrop of growth in the world economy, the Declaration of Alma Ata came just before the 1979 oil crisis, which triggered a debt crisis and global recession (Chan 2008). And while the global AIDS response benefitted from fear among powerful states that the disease could evolve into a global security threat (Lisk 2010), the Health for All strategy did not. However, if we understand the human right to health as an ‘emergent right’ (Chapman 2016) and the international duties it entails as ‘far from settled’ (Tobin 2012), and if we understand human rights as potential levers for civil society, not as a force in itself, then we can conclude that the lack of concrete claims hindered the traction of the health for all strategy.

Universal Health Coverage, the Right to Health, and Global Health Politics The World Health Report: Primary Health Care (Now More Than Ever) signaled WHO’s return to the aspirations of the Declaration of Alma Ata (WHO 2008; Chan 2008). This report introduced the concept of UHC to a wider audience. WHO presented UHC as ‘a practical expression of the concern for health equity and the right to health’ (WHO 2012).

Human Right to Health   507 Not everyone agrees. According to Birn, Pillay, and Holt (2017, 500), ‘UHC—unless explicitly focused on public health care systems strengthening—is a misguided approach, justified by certain legitimate concerns around catastrophic health spending, but offering the likelihood of large-scale rapacious health care system penetration by— and channeling of resources to—private interests that reinforce health care system inequity and stratification’. We have argued that UHC could be the practical expression of the right to health if national and international responsibilities are clearly articulated (Ooms et al. 2014). Thus far, they are not. UHC is most often presented as a domestic technical and financial challenge (WHO 2016), which means that UHC ‘as is’ is unlikely to influence global health politics. Furthermore, some of UHC’s strongest supporters among NGOs based in ­high-income countries—assumed to be the most influential when it comes to global health politics—have made an explicit choice to focus on domestic resource mobilization rather than international financing. In a collective blog, representatives of Save The Children, PAI, and Global Health Advocates (Wright et al. 2016) argue for ‘a paradigm shift toward domestic resource mobilization (DRM)’. Their main arguments are that ‘[a]id budgets [are] unreliable and often restricted to donor priorities, are now stagnating or reducing.’ They commit to and invite others to take a ‘75:25 DRM Pledge’: ‘We call for the UHC2030 meeting and the events happening worldwide for UHC Day to dedicate at least 75 percent of their time and attention to national domestic resources.’ While we sympathize with the arguments, we fear that if only 25 percent of the time and energy spent on UHC in international fora will focus on the global health politics of UHC, UHC may follow the same path as PHC: national or domestic resource constraints will be used as the argument to advocate for selective UHC. The right to health could be an important lever for increasing domestic resource allocation, but if NGOs based in high-income countries fail to use the right to health to demand their governments contribute to international financing, the argument will have reduced value for their NGO counterparts in low- and middle-income countries. Furthermore, international financing will not come to a halt; it will continue to be used for the priorities of the states providing it (for infectious disease control, as realists would predict).

Conclusion Looking for a norm to which all or a majority of states will adhere or could adhere, and that could convince them to steer global health politics beyond the narrow self-interests of the most influential states, the right to health seems an obvious candidate. It is enshrined in treaties that the vast majority of states have signed and ratified. However, there are serious obstacles to using the right to health in that way. First, although human rights are said to be rights everyone has by virtue of being a human being, the original concept was intended to describe rights people have by virtue of being citizens of given

508   Gorik Ooms and Rachel Hammonds societies. The understanding and acceptance of international duties is still in its infancy (Vandenhole 2015). Second, the right to health is an entitlement right; it is shorthand for a basket of freedoms and entitlements, but that basket is filled with mostly entitlements. Accepting international duties for human rights entitlements comes with a cost for wealthier states, and they are reluctant to accept that cost. Third, human rights work as a lever, not as a force; their power depends on how they are being used by civil society organizations. Global HIV/AIDS activism successfully used the right to health to make influential states adopt concrete measures: allowing low- and middle-income countries to purchase generic medicines, generating an international funding stream, and making the World Bank and the IMF accept increased public expenditure. In contrast, the Alma Ata movement did not demand concrete measures from the international community, as it was focused on domestic responsibility. If one wants to use the right to health as a lever for global health politics that enable UHC, one of the main challenges will be to build a coalition of civil society organizations around concrete measures.

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chapter 26

R eporti ng Disease Ou tbr ea ks i n a Wor ld w ith No Digita l Bor ders Sara E. Davies

Since they were signed in 2005, the revised International Health Regulations (IHRs) have guided states on their disease outbreak response, verification, containment, and alert procedures. The revised IHRs reflect the fact that in a world of fast-paced, globalised travel and trade, early detection of communicable disease has become ever more important to prevent the rapid spread of disease. However, the tools to facilitate surveillance and reporting, detection, and communication must be as fast paced as the movement of the outbreak. This sense of urgency has prompted a pivot to technology as the best solution to facilitate disease alerts without compromising continued travel and trade. A new requirement of the revised IHRs, therefore, was that states should promptly communicate with the World Health Organization (WHO), and amongst each other, about outbreak events that might meet the criteria of a public health emergency of international concern (PHEIC). This requirement also addressed the reluctance states might have about reporting outbreaks, for fear of the potential economic impact from reduced travel and trade, as well as the potential for reputational risk. To ensure improved communication of outbreak events, the revised IHRs introduced timelines for communicating disease outbreak reports (24/7 hour notice to WHO of suspected outbreaks through appointment of an IHR focal point within government; 48 hours to verify a suspected outbreak). In an apparent break with the state’s monopoly on reporting outbreaks, the revised IHRs stipulated that nonstate actors (broadly defined) could also directly communicate suspected outbreak events to WHO. Under article 9 (WHA 2005), WHO may take into

514   Sara E. Davies account ‘sources other than [the state] for notifications or consultations’ and ‘assess these reports according to established epidemiological principles and then communicate information on the event to the State Party in whose territory the event is allegedly occurring’ (article 9.1). In 2016 more than 60 percent of WHO’s first news of outbreak reports came from ‘unofficial sources’ (sources other than the state), which include electronic media, discussion sites, social media, and Internet surveillance response programmes (ISRPs) (WHO 2016). Referred to as ‘digital disease detection’ (DDD), ISRPs trace ‘big data’ patterns in cyberspace to detect risk, as well as scan news and media websites for higher than usual reports of disease outbreaks (Lazer et al. 2014; Vayena et al. 2015). Big data algorithms are constantly finessed to predict the next outbreak. This includes text mining of social media pages; doing Google searches on terms such as ‘flu’ or ‘outbreak’; and tracking human behaviours such as purchasing patterns from pharmaceutical sites, the monitoring of local news reports, and filtering social media discussions on platforms such as Twitter, Facebook, and Weibo. These methods supply ISRPs—and potentially WHO—with early reports or rumours of novel disease outbreaks (Roberts and Elbe 2016). A recent example of how this method works is the tweeting activity surrounding the first case of Ebola haemorrhagic fever in Nigeria in July 2014, which occurred days before official confirmation by the Nigerian government. In this case, rather than seeing social media as a site of unverified rumours, the Nigerian government harnessed social media to good effect to communicate the spread of the outbreak (Odlum and Yoon 2015). However, the ISRPs conducting DDD continue to attract controversy and face challenges, largely centred on the presumed benefits of digital detection relative to more traditional public health surveillance and response and questions of whether the former undermine the latter. The advantage of digital detection is that it has the potential to prepare communities and governments to contain a deadly outbreak (Brownstein, Freifeld, and Madoff 2009). However, ISRPs cannot mount investigations into outbreak rumours, nor can they erect containment responses; the WHO director-general (DG) and the government of the affected state are the only actors with the authority to act on rumours supplied by an ISRP. Acting on informal rumours carries great political risk, especially for WHO. As the Ebola outbreak in West Africa in 2014 tragically demonstrated, ISRPs do not exist primarily because WHO is often uninformed about an outbreak. Rather, ISRPs exist because nonstate actors have and will report against the wishes of governments that seek to deny the existence or extent of an outbreak (Ebola Interim Assessment Panel 2015, 10). This has the potential to put WHO on a collision course with some of its member states. Other questions pertain to the ethics of data collection and usage and the lengths ISRPs may go to in conducting individual-level surveillance required for digital detection in the name of health security. Critics of big data contend that public health surveillance that relies on digital methods facilitates the growth of the surveillance state. The danger here is that excessive surveillance could be legitimised in the name of health security, raising difficult questions about how to balance the demands of public health and the individual’s right to privacy (Calain and Abu Sa’Da 2015; Vayena et al. 2015). This is a

Reporting Disease Outbreaks    515 particularly pressing question in politically suppressive states, where the information gathered could be used to limit individual freedoms (Fung, Russon Gilman, and Shkabatur 2013). This chapter explores the contemporary topography of ISRPs and examines the challenges and controversy their work elicits when they provide information on suspect outbreak reports to WHO and on their servers. The first section of the chapter provides a brief history of ISRPs up to their contemporary inclusion in the revised IHRs. The second part of the chapter explores the practical challenge of acknowledging ISRPs’ right to report under the IHRs. The case of the Middle East respiratory syndrome (MERS) outbreak in Saudi Arabia in 2012 is then examined to illustrate the particular tensions that arise in permitting nonstates to report on disease outbreak events within states with tightly regulated social media spaces. The MERS case illustrates the critical challenge WHO faces in managing its need for ISRPs whilst also seeking to avoid political blowback from states that do not want outbreak events to be reported on these sites. The chapter argues in the conclusion that to perform this delicate balancing act, WHO is best placed to develop standard operating guidelines on the growing ISRP sector and its role in reporting under the revised IHRs.

The Challenge: ISRPs’ Right to Report (and to Be Heard) The surveillance and reporting chain in local systems begins with detection—usually through a health clinic—which relays news of the suspected outbreak to a central health ministry. National health ministries have the option to verify before reporting the incident (on a website, in a press release, or to WHO). If the disease falls under Annex 2 of the revised IHRs (2005), a government is expected to immediately report an outbreak to WHO. Annex 2 is a matrix that states and WHO uses to determine whether the outbreak must be reported to WHO. It lays out when the outbreak should be reported if suspected (particularly that a state should not wait for laboratory verification); it provides a list of suspected disease outbreaks that must be reported to WHO; and it provides a list of outbreak events where, if the outbreak is unknown, at what point the IHR focal point must notify WHO. The national IHR focal point can relay the report to WHO headquarters in Geneva or to one of the six WHO regional offices, as occurred in March 2014 when an outbreak of Ebola in Guinea was reported to the African regional office. In the past when this has not happened—due to a government concealing the extent of an outbreak (e.g., the 2003 outbreak of severe acute respiratory syndrome [SARS] in the People’s Republic of China) or a poorly functioning surveillance system (the 2009 H1N1 influenza outbreak in Mexico)—alternative reporting sources were essential in relaying to WHO and to neighbouring states disease surveillance information that a state was reluctant to provide or did not have.

516   Sara E. Davies This raises the question of under what authority WHO—a body whose membership consists solely of states—can receive reports from nonstate actors about a disease outbreak located in a member state. When states adopted the revised IHRs in May 2005, they agreed to openly and promptly report outbreaks with the potential for ‘international spread’. What was significant about the IHRs’ revision was a shift from a model focused exclusively on alerting the international community about an outbreak (and taking relevant quarantine measures) to the adoption of a ‘legal instrument [that sought] to ensure global health security through a collective approach’ (Li and Kasai 2011, 7). Pre-emption was the goal attached to the revised IHRs, and this marked out the importance of reporting: states have to know in order to contain. Baker and Fidler (2006, 1062) argue that one particular strength of the revised IHRs was the inclusion of a provision in article 9 that permitted WHO to receive reports of disease outbreak events from sources other than the affected state.1 They argue that article 9’s significance lies in the potential for WHO to ‘cast its surveillance network beyond information it receives from governments. . . . [This would] avoid being blocked by governmental failure to comply with reporting requirements’. The significance of article 9 lies in the expectation that to facilitate a transparent surveillance and reporting system, WHO must be permitted to receive reports of disease outbreaks from sources other than the state. Despite World Health Assembly (WHA) approval of this practise in the 2001 resolution ‘Global Health Security’ (WHA 2001), it was a contentious practise during the SARS outbreak in 2003 (Cortell and Peterson 2006; Kamradt-Scott 2015). In addition to reports from health ministries, the WHO Secretariat relied upon reports from media, scientists, and individuals about suspected SARS outbreaks (Heymann and Rodier 2004; Heymann, Mackenzie, and Peiris 2013). In the case of China, the state reported to WHO headquarters (for some months) a very small SARS caseload, whilst WHO was simultaneously being informed by nonstate sources within and outside China that the extent of the infection was much greater (Fidler 2004). Controversially, WHO used these reports to request the Chinese government check its cases, issued travel advisories against the country, and publicly rebuked the government for not revealing the full extent of the SARS virus, particularly in Beijing. The fact that WHO’s use of nonstate reports was formally adopted under article 9 in the revised IHRs, agreed to in the aftermath of SARS, was regarded as a vindication of the WHO DG’s efforts to demand more reporting transparency from states and to attach consequences to lack of transparency (Mack 2007). The revised IHRs were considered a ‘new dawn’ for global health, whereby WHO may receive reports from nonstate sources and act upon them to elicit further information from a recalcitrant state (Rodier 2007). Since the euphoria over article 9, little discussion has followed addressing the challenge of realising its promise. In particular, how does WHO persuade affected states of the need to investigate outbreak reports issued by nonstate actors? And how does WHO respond to outbreak reports from nonstate actors that appear credible but are denied by the host state? The advantage of article 9 is that it permits WHO to listen to other sources and not solely rely on a government, particularly if that government is suspected of

Reporting Disease Outbreaks    517 covering up the true extent of a health crisis. However, at the same time, WHO is obliged under the same instrument to assist governments with the creation of effective risk communication strategies to control and direct the flow of information through one source, the health ministry or the executive level of the government (Ijaz et al. 2012). Contrary to the view that surveillance is an unwelcome intrusion on the state’s authority and capacity to detect, the use of big data for digital disease detection has actually proven useful for states. Examples include claims that the Nigerian government used social media analytics and open data sharing to successfully respond to the Ebola outbreak in Lagos in 2014, as well as improving timely responses to tuberculosis and polio outbreaks (Pisani et al. 2016). The benefit of ISRPs for their users—whether states or WHO—is their analytical capability to distinguish the ‘signal from the noise’ (Brownstein et al. 2008, 1019). It is important at this point to clarify between ISRPs— which may use, amongst other tools, social media to detect outbreak events—from DDD, which seeks to predict disease outbreak events from social media usage. Some DDD, such as the GoogleFluTrend prediction of double the number of flu cases in the United States in the 2014 flu season, has caused much embarrassment and misappropriation of health resources (Lazer et al. 2014). In addition, there is evidence that on the (rare) occasions a government tweets outbreak events, social media users do not engage at any level that would suggest a transformative potential of DDD from traditional public health messaging (Hornmoen and McInnes, 2016). In the case of ISRPs, there have also been situations in which their reports could not be verified, posed a resourcing burden, or were politically unwelcome. Medicins Sans Frontiers (MSF) argued that its focus on developing a disease surveillance network in Haiti after the 2010 earthquake provided great aggregated data reports—but could not detect the cholera outbreak (Polonsky et al. 2013). There have also been situations in which the ISRPs were ignored; in the recent case of Ebola viral disease in West Africa in 2014, ISRPs were receiving reports from nonstate actors that contradicted the official reports in Guinea, Liberia, and Sierra Leone, and WHO headquarters chose to listen to the states (Gostin, DeBartlo, and Friedman 2015). Since the adoption of the revised IHRs, much attention amongst ISRPs has been devoted to improving their efficiency in detecting outbreaks (Hitchcock et al. 2007; Castillo-Salgado 2010; Collier 2010). There has also been increased focus on ISRP interoperability with the Global Health Security Initiative (GHSI) (launched by the G72 countries in 2001), including the creation of a GHSI Strategic Framework, which seeks to promote a common platform for detection, reporting, and response amongst ISRPs (Hartley et al. 2010; GHSI 2014; Dion, AbdelMalik, and Mawudeku 2015). Long established ISRPs such as Global Public Health Information Network (GPHIN, located in the Public Health Agency of Canada) and ProMED (in partnership with Google’s HealthMap since 2014) rely on two information streams: big data algorithms to detect and report disease outbreaks and human analysts who sift through the reports to detect the ‘signal’ in the noise. GPHIN and ProMED have been referred to as ‘platinum’ sites for their reliability (Collier 2012), which comes from their use of human analysts—epidemiologists and language specialists—whose roles are to interpret the data collected. Under GPHIN,

518   Sara E. Davies analysts with language proficiency in Arabic, Farsi, English, Spanish, Russian, Chinese, Portuguese, and French can sift through thousands of reports daily to determine which ones should be placed on the subscriber-only alert page (which can also be emailed to subscribers). GPHIN was developed in a partnership between WHO headquarters and the Public Health Agency of Canada in 1996. It was one of the first ‘real-time’ surveillance networks, and originally reports were only issued to fee-paying subscribers. GPHIN, whose staff are all Public Health Agency of Canada employees, has gone through various iterations and is currently a 24/7 early warning system for infectious disease outbreaks that is open source to any subscriber. ProMED has been providing infectious disease alerts to its subscribers since 1994, using volunteer moderators and analysts. It has been aligned with the International Society for Infectious Diseases since 1999 and relies on donations for support. ProMED reports are published on the HealthMap site (http://www.healthmap.org/en/), and they now share a visual world map of disease outbreaks that is updated 24/7. ProMED describes itself as ‘open to all sources and free of political constraints. Sources of information include media reports, official reports, online summaries, local observers, and others’ (ProMED 2016). There are seventy thousand subscribers to ProMED across 185 countries. Contemporary Internet-based health surveillance tools use various techniques to report (mostly) infectious disease outbreaks. Some primarily use text mining of media reports for disease outbreak events (e.g., MedISys);3 others incorporate algorithms, media reports, and correspondence from users, which are distributed to subscribers (e.g., ProMED, GPHIN). Still others attempt to refine ontology software so that it may conduct both text mining and language translation for reports (e.g., PULS Project: Surveillance of Global News Media).4 To date, GPHIN and ProMED are the longest serving infectious disease surveillance networks and the only two to rely on human analysts prior to online publication of reports. When GPHIN or ProMED reports a disease outbreak that has not been confirmed by a state, tensions have and can immediately escalate if that state did not want the outbreak reported (Madoff and Woodall 2005). In previous situations, including the Nipah virus outbreak in Malaysia (1997), SARS in China (late 2002), and MERS in Saudi Arabia (2012), direct notification of these outbreaks from ‘informal’ channels (healthcare workers, laboratories, and ‘laypersons’) has been made at great personal risk (Madoff and Woodall 2005; Branswell 2013b; Dion, AbdelMalik, and Mawudeku 2015). The capabilities of ISRPs vary widely in both type and performance (Castillo-Salgado 2010, 98–100; Hartley et al. 2010, 3). The type of intelligence generated depends on each ISRP’s functionality, accuracy, and coverage. However, the right to act on these reports rests with WHO, specifically the WHO DG, and the political consequences of using such reports explain the variation in their use by successive DGs. Gro Harlem Brundtland, for example, proactively sought to forge relationships with ISRPs, and WHO epidemiologists within the infectious disease section often formed partnerships to investigate reports (Grein et al. 2000). Her successor, Lee Jong-wook, also promoted a series of global surveillance systems—global tuberculosis, global vaccine immunisation, and global polio surveillance—that have retained nonstate- and state-informed surveillance

Reporting Disease Outbreaks    519 to this day. Margaret Chan’s record of acting on article 9, however, was varied and was tested more than the two previous DGs. During her tenure (2007–2017) there were serious cross-border and cross-regional outbreaks of H1N1, MERS, poliovirus, Ebola, Zika, and yellow fever, leading to the creation of six IHR Emergency Committees. At this stage there is little evidence to support shifting the entire surveillance and response model to social media tools to both predict outbreaks and manage risk communication during outbreak emergencies. However, the ISRPs to date—particularly GPHIN and ProMED—have had varied experiences. Their success was significant enough to lead to WHO obtaining the right to use the information provided by these information providers (and other nonstate entities) in the revised IHRs. However, the influence that ISRPs have on WHO behaviour in compelling states to report outbreaks has tended to depend on the commitment of the WHO DG. The next section explores a contemporary case of nonstate reporting concerning MERS and the impact when such a report has been made against the wishes of the affected state. The first MERS report in Saudi Arabia and the WHO DG’s reaction to this report exemplify the complex and political nature of ISRPs as well as the less acknowledged—but crucial—relationships amongst political openness, access, coverage, and freedom to report.

The Controversy from Nonstate Reports What is the perceived benefit from a global disease surveillance system? First, some contend that there is little added benefit and that the focus is misplaced. The original attraction of global disease surveillance is to warn developed nations of the ‘North’ about diseases coming from the developing ‘South’. The perception that states ‘hide’ outbreaks is rarely accurate; most often states just don’t know (Kamradt-Scott and Rushton 2012). Therefore the real solution to protecting the ‘North’ and the ‘South’ is a strong local (nationally run) health surveillance system. Others contend that no surveillance system can address inequity: its capacity and purpose is to provide greater health security. Global disease surveillance therefore provides an additional surveillance service to alert and prepare multiple states for a potential outbreak; a global system has the technological capacity to detect behaviours that could provide early waning to the state affected, and they are able to communicate a coordinated message to multiple users (Grein et al. 2000; Collier 2012). A third argument is that global disease surveillance is an insurance policy—it assists in those situations when a state cannot accurately report an outbreak situation and is the backup for regions and the international community in situations when a state chooses not to report an outbreak situation (Fidler 2004). The WHO-appointed Review Committee on the Functioning of the International Health Regulations on Pandemic Influenza (H1N1) 2009 noted in 2011 that there were unresolved tensions in how to manage (a) WHO’s need for information (which may not

520   Sara E. Davies reliably come from affected states), (b) its right to acquire information from nonstate sources, and (c) the need for state verification to proceed with outbreak response recommendations: Although WHO has a broad mandate to share urgent information on public-health events, WHO usually obtains agreement first from the affected State Party. The proc­ess of consulting with States Parties may delay posting on the EIS [Event Information System]. There is an inherent tension between WHO’s obligation to inform other States Parties and the affected State Party’s interest in avoiding potential social and economic consequences. WHO tries to balance these priorities and sensitivities through dialogue, respecting the requirements in Article 11. For the EIS to become an even more valuable tool, States Parties should be more willing to let WHO share information. The WHO EMS was developed to track information on public-health events.  (IHR Review Committee 2011, 54)

In 2015 the Ebola Interim Assessment Panel, appointed by the WHO DG to examine the organisation’s performance during the 2014 outbreak in West Africa, reinforced this view. It noted that member states have ‘largely failed’ to implement the IHRs’ core capacities, since no functional in-country surveillance was available to detect the extent of an infectious disease outbreak (Ebola Interim Assessment Panel 2015, 11). In addition, the panel noted a deliberate intention by the states most affected by the outbreak (Guinea, Sierra Leone, and Liberia) to delay their own government-issued reports whilst denying outbreak reports from nonstate sources. Despite the authority of WHO to investigate these nonstate reports, and despite repeated warnings from nonstate actors that the situation was grave, WHO senior management did not challenge the actions or denials of these states (Ebola Interim Assessment Panel 2015, 12). How can we explain such confusion if article 9 is as clear-cut as others have argued? To help answer this question, we now examine an earlier case, the first outbreak of MERS in Saudi Arabia in 2012. In June 2012, a patient with a severe respiratory disease was admitted at the Dr Soliman Fakeeh Hospital in Jeddah, Saudi Arabia. When the patient did not improve, Dr Ali Mohamed Zaki, an Egyptian national and professor of microbiology at the hospital, took a sample of sputum to identify the cause of the sickness. When he could not detect a positive for any of the suspected diseases, he contacted Dr Ron Fouchier at Erasmus Medical College in Rotterdam, Netherlands. Suspecting a novel virus, Dr Zaki sent a sample to be tested in Dr Fouchier’s lab. Dr Zaki argues that he ‘complied with procedures by submitting a virus sample and associated clinical data to the Saudi Ministry of Health on 18 June’ (Butler 2013). There was no follow-up from the health ministry, so he continued to cooperate with Dr Fouchier’s lab. The Saudi Ministry of Health has since said that it does not deny regular procedures were followed, but that Dr Zaki did not inform them that the sample was suspected to be a novel virus (Butler 2013). In September, Dr Fouchier reported to Dr Zaki that the Erasmus lab had detected a novel coronavirus (Zaki 2012). Two events then had an immediate impact on Dr Zaki. On the same day that he notified the Saudi government of the coronavirus finding by the Erasmus lab, he notified the

Reporting Disease Outbreaks    521 international community via an ISRP, ProMED (Barboza et al. 2013). The email from Dr Zaki—after verification by the ProMED team—was distributed to thousands of subscribers (government, laboratory, non-government, civil society, media, universities, individuals) around the world. Dr Zaki later explained that he decided to notify via ProMED for two reasons. First, he believed that the potential risk to the upcoming Hajj pilgrimage necessitated immediate notification to travellers and to hospitals internationally, who might see individuals with coronavirus symptoms on the pilgrims’ return from Mecca. A related second reason he went to ProMED was that he lacked confidence in the Saudi government’s sharing this diagnosis to ensure that countries could detect MERS infections (Sample 2013).5 At the same time, the Erasmus lab named the virus human betacoronavirus 2c EMC (hCoV-EMC) and set up a material-transfer agreement (MTA) for virus samples. An MTA, argues David Fidler (2013), was not unusual in this area, where there are usually agreements concerning the safe transfer of biological samples. This MTA preserved ‘Erasmus’ ownership of the virus samples it had received, protected its ability to obtain intellectual property rights on research outcomes from that sample, and required labs that requested the virus to demonstrate necessary biosafety level status to handle the virus’ (Fidler 2013). However, the MTA meant that to test the Erasmus sample, the Saudi government would need to sign an MTA with Erasmus. The government responded by immediately dismissing Dr Zaki, revoking his working visa, which forced him to return immediately to Egypt. By May 2013 there were thirty-four laboratory-confirmed cases of the new MERS coronavirus (De Groot et al. 2013). It was revealed during this time that possibly the first case was an outbreak of suspected pneumonia amongst healthcare workers in a Jordanian hospital in April 2012. During 2013, reports started to appear questioning the degree to which the Kingdom of Saudi Arabia, in particular, was being forthcoming about the volume of MERS cases treated there (Branswell 2013a; European Centre for Disease Prevention and Control 2013). For most of 2013, only laboratory-confirmed cases were reported to WHO, despite the MERS IHR Emergency Committee recommending that all states report suspected as well as confirmed cases (Ministry of Health Saudi Arabia 2013; WHO 2013). In early 2014 there was a proliferation of social media activity—on Twitter and Facebook—amongst, apparently, healthcare workers within the kingdom, who alleged that the extent of the outbreak was being concealed (Levy and Binshtok 2014).6 Ten laboratory-confirmed cases of MERS were reported from Abu Dhabi in April 2014 (WHO 2014a), the same time that social media reports concerning MERS in Saudi Arabia reached their height. On May 1, WHO issued the following statement: ‘Saudi Arabia has provided information on 138 cases identified between 11 to 26 April 2014 in the country, including preliminary details of cases and deaths associated with the outbreak in Jeddah. WHO will update the global total of laboratory-confirmed cases of infections with MERS-CoV, including deaths, based on official information provided by Saudi Arabia as quickly as possible’ (WHO 2014b). WHO was permitted to enter Saudi Arabia to assess the government’s handling of MERS, whilst at the same time a cabinet order directed all Saudi news media to quote

522   Sara E. Davies only official sources on the disease. The Ministry of Health allegedly advised healthcare workers that they could be imprisoned for disclosing any information issued by the ministry, which included information on infectious disease outbreaks (Al Omran et al. 2014). The same month, the health minister and deputy health minister were fired for allegedly failing to disclose full reports (Branswell 2015). After the WHO visit, the Saudi government released a statement claiming that it would review procedures for reporting cases (Ministry of Health Saudi Arabia 2014), but some governments (United Kingdom) and regional organisations (i.e. European Centre for Disease Prevention and Control) continued to express concern about the limited amount of information coming out of the region about the virus, fuelling ongoing queries about the timeliness of and full details being provided in outbreak reports (European Centre for Disease Prevention and Control 2014; Branswell 2015).7 Very little was said about the Saudi government’s transparency regarding MERS by WHO, which is what made comments at the 2013 WHA from its DG (Dr Chan) all the more curious. In May 2013, Saudi Arabia deputy health minister Zaid Memish had presented to the WHA the MTA placed by the Erasmus lab on its sample of MERS (which had been sent by Dr Zaki). Dr Memish argued that this MTA had prevented the Saudi government from studying the virus to improve its own diagnostics. Dr Chan not only sided with Dr Memish, but also argued in her subsequent speech at the WHA that delegates must ‘share your specimens with WHO collaborating centers, not in a bilateral manner. Please, I’m very strong on this point, and I want you to excuse me. Tell your scientists in your country, because you’re the boss. You’re the national authority. Why would your scientists send specimens out to other laboratories on a bilateral manner and allow other people to take intellectual property rights on a new disease?’ (Fidler 2013). David Fidler and others have argued that this statement, which was supported by WHO assistant general for health security and environment Keiji Fukuda, was not only incorrect but carries serious implications for future Dr Zakis and ISRPs (Butler 2013; Fidler 2013). Chan’s comments—insisting on national authority over specimen control— gave no consideration to Dr Zaki’s claim that he had approval to send the virus, nor did it acknowledge the importance of his alert to ProMED, which spurred international action to detect the virus. The ProMED report directly led to a patient in London being tested for the virus in the same month, and in effect alerted the international community to the new disease (Zaki et al. 2012). Dr Chan’s exhortation to ‘[t]ell your scientists in your country, because you’re the boss’ has implications beyond situations in which scientists need international assistance to diagnose an outbreak. This statement does not acknowledge the right of the nonstate actor to report despite its inclusion under article 9 of the IHRs. In this case, there was an obvious tension between supporting a national government, virus sample sharing, and rapid diagnosis, especially in a situation where the state was unable to diagnose the pathogen but wanted to maintain control over the reporting of the outbreak and the use of sample(s). There was a further tension here because WHO wanted to be part of the diagnostic process and resented others such as Erasmus and ProMED

Reporting Disease Outbreaks    523 adopting roles that WHO believed were its responsibility. This position is challenged by Dr Chan’s own recent observation that ‘any delay’ in diagnostics compromises WHO’s response to assess whether the situation constitutes an outbreak of international concern (Chan 2015). Such delays cost lives and make it more difficult to contain a virus. However, it appears from her MERS statement that Dr Chan’s principal consideration was the need to include WHO collaborating centres in all shared diagnostic processes. Failure to include WHO in the diagnostics process will lead to delays in global alerts and notices concerning an outbreak, but Chan’s statement implied that unless WHO was itself involved, the organisation would not accept reports from unofficial sources, view them as legitimate sources, or protect the right of such reporting platforms to exist. However, this denies the political and reporting culture of countries that may lead individuals to approach ISRPs (UNGA 2013, 10–11). Saudi Arabia is widely viewed as a repressive environment for media and social media users (Callanan and Dries-Ziekenheiner 2012; Freedom House 2015; Reporters Without Borders 2015). It has low levels of transparency, rule of law, and judicial independence. Access to the Internet and use of social media platforms are rapidly growing, with 63.7 percent of the population of twenty-nine million having access to the Internet (Freedom House 2015). The Saudi government retains tight controls on its usage and routinely blocks posts, even imprisoning individuals if there is ‘sensitive political content’ (Reporters Without Borders 2015). In such an environment, it is arguably difficult to trust unreservedly the public communication of the government about emergencies, and it is also difficult to challenge the government’s version of events, particularly when it is coupled with the introduction of harsh penalties for those who provide information directly to international bodies without first filtering it through the government. This case reveals three tensions in the operationalisation of article 9 under the IHRs (2005) and the contribution of ISRPs to outbreak detection. First, the individual right to report potentially challenges the state’s monopoly on information. Reporting under Article 9 presents significant risks for the individual or non-government organisation (Wirtz 2008; Shkabatur 2011). Open source reporting depends on political environments that permit (if not condone) full disclosure and facilitate open communication (Rød and Weidmann 2015). Related to this is the second point: the type of global reporting system articulated in article 9 relies on individuals knowing about an outbreak situation and being able to communicate such information. Under article 9, states are expected to respond to WHO communications based on nonstate reports within twenty-four hours, and the source of the report is permitted to remain confidential. This may not be of paramount importance for an international ISRP such as GPHIN or international non-governmental organisations (NGOs) such as MSF, but for individuals from local NGOs who may wish to inform these sites or WHO itself about outbreak events, confidentiality may be vital. In the tightly controlled information technology and journalistic space of Saudi Arabia, health workers who reported on MERS cases lost their jobs and were threatened with imprisonment (Knickmeyer and McKay 2013). Given the risk of reporting, there is also the (even) less acknowledged problem of the

524   Sara E. Davies false positive: What if the report is wrong and WHO’s action risks the lives of those who reported? The third tension within article 9 stems from multiple source reporting (O’Malley, Rainford, and Thompson 2009). Whilst the MERS outbreak in Saudi Arabia revealed how attempts to manage crises through secrecy fuel suspicion and panic (Roberts 2007; Cyranoski 2013), the goal should be for states to improve their own capacity to detect and verify disease outbreak events. Article 9 was originally promoted as an opportunity for states to improve their own surveillance and reporting practises to ‘beat’ those who report under article 9 (Rodier 2007). Of course, an alternative view is that article 9 drives states to be more secretive and exercise control over freedom of information exchange amongst those in the health sector (Heymann and Rodier 2004; Castillo-Salgado 2010). This is no doubt controversial, but any measurement of a state’s adherence to the revised IHRs requires understanding the type of transparent political institutions required to permit technical proficiency in surveillance and response (Davies 2012). There is growing evidence that in low-capacity environments where health systems are already stretched, the use of media reports to inform surveillance and response to disease outbreaks can assist with outbreak detection and containment (Ao et al. 2016). However, such a system requires local media to have freedom to report events as they occur.

Conclusion The existing ISRPs face multiple hurdles, including creating uniformity in reporting to build trust in the concept of DDD, the capacity to differentiate to survive competition, and the proficiency to provide timely and accurate reports whilst complementing—not competing with—state surveillance activity. The existence of a provision to permit nonstate reports under the revised IHRs legitimises WHO’s receipt of such reports and taking action based on them. As such, the challenge and controversy that has arisen during H1N1, MERS, and Ebola outbreaks may point to WHO’s dereliction in fulfilling the promise of article 9. But WHO’s wariness to openly challenge a state’s report on the basis of information received under provisions of article 9 also points to what was forgotten when the IHRs were adopted in 2005. It is not only WHO headquarters that wants to know of an outbreak that could risk health and trade. All states want to know, and they especially want to know if it is on their borders. States agreed to article 9 in part because of the inevitability of information leakage, and because the IHRs included the provision for states to develop their capacity to manage the detection process and communications required during an outbreak. The critical challenge that ISRPs and WHO may continue to face is political blowback from states that do not want outbreak events to be reported on these sites. To date much concern has focused on the potential unethical use of surveillance methods to collect big data. This chapter has revealed that whilst those concerns remain legitimate, it is equally important to remain attentive to the ex­ist­ ence of political situations in which excessive reporting restrictions may impede data collection during disease outbreak emergencies.

Reporting Disease Outbreaks    525

Notes 1. Article 9 permits WHO to ‘take into account reports [of outbreak events] from sources other than notifications or consultations and shall assess these reports according to established epidemiological principles and then communicate information on the event to the State Party in whose territory the event is allegedly occurring’ (WHA 2005, article 9). 2. The G7 consists of Canada, France, Germany, Italy, Japan, the United Kingdom, and the United States. 3. See https://ec.europa.eu/jrc/en/scientific-tool/medical-information-system. 4. See http://puls.cs.helsinki.fi/static/index.html. 5. That very month, Zaki’s notification assisted with the identification of a MERS-infected patient in the United Kingdom (Bermingham et al. 2012). 6. According to Levy and Binshtok (2014), ten new cases were reported per day; WHO (2014) reported that since mid-March 2014, over one hundred people had tested positive for MERS in the Jeddah area, and thirty-one of them had died. 7. “More detail and analysis of the evolving events in the Arabian Peninsula is urgently needed to define the source of the infection and to further define the risks posed by this event” (European Centre for Disease Prevention and Control 2014, 16).

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526   Sara E. Davies Brownstein, John  S., Clark  C.  Freifeld, and Lawrence  C.  Madoff. 2009. ‘Digital Disease Detection—Harnessing the Web for Public Health Surveillance.’ New England Journal of Medicine 360: 2153–2157. doi:10.1056/NEJMp0900702. Brownstein, John S., Clark C. Freifeld, Ben Y. Reis, and Kenneth D. Mandl. 2008. ‘Surveillance Sans Frontières: Internet-Based Emerging Infectious Disease Intelligence and the HealthMap Project.’ PLOS One 5 (7): 1019–1024. doi:10.1056/NEJMp0900702. Butler, Declan. 2013. ‘Tensions Linger over Discovery of Coronavirus.’ Nature, January 14. http://www.nature.com/news/tensions-linger-over-discovery-of-coronavirus-1.12108. Calain, Philippe, and Caroline Abu Sa’Da. 2015. ‘Coincident Polio and Ebola Crises Expose Similar Fault Lines in the Current Global Health Regime.’ Conflict and Health 9 (29): 1–7. doi:10.1186/s13031-015-0058-1. Callanan, Cormac, and Hein Dries-Ziekenheiner. 2012. Safety on the Line: Exposing the Myth of Mobile Communication Security. Washington, DC: Freedom House. Castillo-Salgado, Carlos. 2010. ‘Trends and Directions of Global Public Health Surveillance.’ Epidemiologic Review 32 (1): 93–109. doi:10.1093/epirev/mxq008. Chan, Margaret. 2015. ‘WHO Director-General Addresses the Review Committee of the International Health Regulations Focused on the Ebola Response, Opening Remarks at the Review Committee on the Role of the International Health Regulations in the Ebola Outbreak and Response.’ http://www.who.int/dg/speeches/2015/review-committee-IHRs -ebola/en/. Collier, Nigel. 2010. ‘What’s Unusual in Online Disease Outbreak News?’ Journal of Biomedical Semantics 1 (2): 1–18. doi:10.1186/2041-1480-1-2. Collier, Nigel. 2012. ‘Uncovering Text Mining: A Survey of Current Work on Web-Based Epidemic Intelligence.’ Global Public Health 7 (7): 731–749. doi:10.1080/17441692.2012.699975. Cortell, Andrew  P., and Susan Peterson. 2006. ‘Dutiful Agents, Rogue Actors, or Both? Staffing, Voting Rules, and Slack in the WHO and WTO.’ In Delegation and Agency in International Organization, edited by Darren G. Hawkins, David A. Lake, Daniel L. Nielson, and Michael J. Tierney, 255–280. Cambridge, UK: Cambridge University Press. Cyranoski, D. 2013. ‘Scientists Look to Saudi Arabia for Coronavirus Clues.’ Nature, May 17. http://www.nature.com/news/scientists-look-to-saudi-arabia-for-coronavirus-clues-1.13000. Davies, Sara  E. 2012. ‘Informal Disease Surveillance Networks.’ Global Change, Peace and Security 24 (1): 95–107. doi:10.1080/14781158.2012.641272. De Groot, Raoul J., Susan C. Baker, Ralph S. Baric, Caroline S. Brown, Christian Drosten, Luis Enjuanes, et al. 2013. ‘Middle East Respiratory Syndrome Coronavirus (MERS-CoV): Announcement of the Coronavirus Study Group.’ Journal of Virology 87 (14): 7790–7792. doi:10.1128/JVI.01244-13. Dion, M., P. AbdelMalik, and A. Mawudeku. 2015. ‘Big Data and the Global Public Health Intelligence Network (GPHIN).’ Canada Communicable Disease Report 41 (9): 209–214. Ebola Interim Assessment Panel. 2015. Report of the Ebola Interim Assessment Panel—July 2015. Geneva: World Health Organization. http://www.who.int/csr/resources/publications /ebola/ebola-panel-report/en/. European Centre for Disease Prevention and Control. 2013. ‘Updated Rapid Risk Assessment MERS-CoV, 17 May.’ http://ecdc.europa.eu/en/publications/Publications/risk-assessment -middle-east-respiratory-syndrome-coronavirus-MERS-CoV-17-may-2013.pdf. European Centre for Disease Prevention and Control. 2014. ‘Rapid Risk Assessment: MERS-CoV, 31 May.’ http://ecdc.europa.eu/en/publications/Publications/RRA-Middle-East -respiratory-syndrome-coronavirus-update10.pdf.

Reporting Disease Outbreaks    527 Fidler, David P. 2004. ‘Germs, Governance, and Global Public Health in the Wake of SARS.’ Journal of Clinical Investigation 113 (6): 799–804. doi:10.1172/JCI200421328. Fidler, David P. 2013. ‘Who Owns MERS? The Intellectual Property Controversy Surrounding the Latest Pandemic.’ Foreign Affairs, June 6. https://www.foreignaffairs.com/articles /saudi-arabia/2013-06-06/who-owns-mers. Freedom House. 2015. ‘Freedom of the Press—Saudi Arabia 2015.’ https://freedomhouse.org /report/freedom-press/2015/saudi-arabia. Fung, A., Holly Russon Gilman, and Jennifer Shkabatur. 2013. ‘Six Models for the Internet + Politics.’ International Studies Review 15 (1): 30–47. Global Health Security Initiative (GHSI). 2014. ‘Fifteenth Ministerial Meeting of the Global Health Security Initiative (GHSI) Ministerial Statements Tokyo, Japan, 11 December.’ http://www.ghsi.ca/english/statementtokyo2014.asp. Gostin, Lawrence  O., Mary  C.  DeBartolo, and Eric  A.  Friedman. 2015. ‘The International Health Regulations 10 Years On: The Governing Framework for Global Health Security.’ The Lancet 386 (10009): 2222–2226. doi:10.1016/S0140-6736(15)00948-4. Grein, Thomas W., Kamara O. Kande-Bure, Guénaël Rodier, Aileen J. Plant, Patrick Bovier, et  al. 2000. ‘Rumors of Disease in the Global Village: Outbreak Verification.’ Emerging Infectious Diseases 6 (2): 97–102. doi:10.3201/eid0602.000201. Hartley, David, Noele Nelson, Ronald Walters, Ray Arthur, Roman Yangarber, Larry Madoff, et al. 2010. ‘The Landscape of International Event-based Biosurveillance.’ Emerging Health Threats Journal 3 (1): e1–8. doi: 10.3134/ehtj.10.003. Heymann, D. L., John S Mackenzie, and Malik Peiris. 2013. ‘SARS Legacy: Outbreak Reporting Is Expected and Respected.” The Lancet 381 (9869): 779–781. Heymann, David, and Guénaël R. Rodier. 2004. ‘Global Surveillance, National Surveillance, and SARS.’ Emerging Infectious Diseases 10 (2): 173–175. doi:10.3201/eid1002.031038. Hitchcock, Penny, Allison Chamberlain, Megan Van Wagoner, Thomas V. Inglesby, and Tara O’Toole. 2007. ‘Challenges to Global Surveillance and Response to Infectious Disease Outbreaks of International Importance.’ Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science (3): 206–227. doi:10.1089/bsp.2007.0041. Hornmoen, Harald, and Colin McInnes. 2016. ‘Dialogical Disguise? Crisis Authorities’ Use of Social Media in the UK and Norway during the 2014–15 West African Ebola Outbreak.’ Paper presented at IAMCR 2016, Leicester, United Kingdom of Great Britain and Northern Ireland, 27/07/2016–31/07/2016. On file with author. IHR Review Committee. 2011. Final Report of the IHRs Review Committee (as Presented to 64th WHA): Report of the Review Committee on the Functioning of the International Health Regulations (2005) and on Pandemic Influenza A (H1N1) 2009. Geneva: World Health Organization. Ijaz, Kashef, Eric Kasowski, Ray  R.  Arthur, Frederick  J.  Angulo, and Scott  F.  Dowell. 2012. ‘International Health Regulations—What Gets Measured Gets Done.’ Emerging Infectious Diseases 18 (7): 1054–1057. doi:10.3201/eid1807.120487. Kamradt-Scott, Adam. 2015. Managing Global Health Security: The World Health Organization and Disease Outbreak Control. New York: Palgrave Macmillan. Kamradt-Scott, Adam, and Simon Rushton. 2012. ‘The IHRs Revisions: Socialization, Compliance and Changing Norms of Global Health Security.’ Global Change, Peace and Security 24 (1): 57–70. doi:10.1080/14781158.2012.641284. Knickmeyer, Ellen, and Betsy McKay. 2013. ‘Saudi Efforts to Stop MERS Virus Faulted: Experts Still Don’t Know How People Are Exposed to Mysterious Disease.’ Wall Street Journal,

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Reporting Disease Outbreaks    529 Sample, Ian. 2013. ‘Coronavirus: Is This the Next Pandemic?’ The Guardian, March 16. https://www.theguardian.com/science/2013/mar/15/coronavirus-next-global-pandemic. Shkabatur, Jennifer. 2011. ‘A Global Panopticon? The Changing Role of International Organizations in the Information Age.’ Michigan Journal of International Law 33 (1): 159–214. https://repository.law.umich.edu/mjil/vol33/iss1/508. United Nations General Assembly (UNGA). 2013. Compilation Prepared by the Office of the High Commissioner for Human Rights in Accordance with Paragraph 15 (b) of the Annex to Human Rights Council Resolution 5/1 and Paragraph 5 of the Annex to Council Resolution 16/21. Saudi Arabia, A/HRC/WG.6/17/SAU/2, August 6. New York: United Nations. Vayena, Effy, Marcel Salathé, Lawrence  C.  Madoof, and John  S.  Brownstein. 2015. ‘Ethical Challenges of Big Data in Public Health.’ PLoS Computer Biology 11 (2): e1003904. doi:10.1371/ journal.pcbi.1003904. Wirtz, James J. 2008. ‘Hiding in Plain Sight: Denial, Deception, and the Non-State Actor.’ SAIS Review of International Affairs 28 (1): 55–63. World Health Assembly (WHA). 2001. Global Health Security. WHA54.1. Geneva: World Health Organization. World Health Assembly (WHA). 2005. Revision of the International Health Regulations, WHA58.3: Article 9.a. Geneva: World Health Organization. World Health Organization (WHO). 2013. ‘Middle East Respiratory Syndrome Coronavirus (MERS-CoV). 9 July 2013.’ http://www.who.int/IHRs/procedures/statements_20130709/en/. World Health Organization (WHO). 2014a. ‘Middle East Respiratory Syndrome Coronavirus (MERS-CoV)—Update, 16 April.’ http://www.who.int/csr/don/2014_04_16_mers/en/. World Health Organization (WHO). 2014b. ‘WHO Concludes MERS-CoV Mission in Saudi Arabia, 7 May.’ http://www.emro.who.int/media/news/mers-cov-mission-saudi-arabia.html. World Health Organization (WHO). 2016. ‘Epidemic Intelligence—Systematic Event Detection, Emergencies Preparedness, Response.’ http://www.who.int/csr/alertresponse /epidemicintelligence/en/. Zaki, Ali Mohamed. 2012. ‘Novel Coronavirus—Saudi Arabia: Human Isolate. International Society of Infectious Diseases ProMED-mail.’ September 20. http://www.promedmail.org /direct.php?id=20120920.1302733. Zaki, Ali Mohamed, Sander Van Boheemen, Theo M. Bestebroer, Albert D. M. E. Osterhaus, and Ron  A.  M.  Fouchier. 2012. ‘Isolation of a Novel Coronavirus from a Man with Pneumonia in Saudi Arabia.’ New England Journal of Medicine 367: 1814–1820. doi:10.1056/ NEJMoa1211721.

chapter 27

The Politics of Pa n demic I n flu enz a Pr epa r edn ess Adam Kamradt-Scott

In 2007 the World Health Organization (WHO) declared pandemic influenza ‘the most feared security threat’ because of its ability to spread easily between humans; the difficulty in controlling it; and the number of fatalities inflicted by previous outbreaks, epidemics, and pandemics (WHO 2007, 45). Influenza, in short, is a ubiquitous disease genetically predisposed to mutation and adaptation, making it difficult to develop one definitive, effective countermeasure. Periodically a new strain emerges against which humans have little to no immunity, and influenza vaccines remain our best defense. For these reasons, especially since the start of the new millennium, pandemic influenza preparedness has involved the stockpiling of pharmaceuticals—for those countries that can afford to do so—as the hallmark of ‘responsible government’. This has been actively encouraged by key global institutions such as the WHO, the World Bank, the United Nations (UN), and the International Monetary Fund (IMF). The governance arrangements for pandemic influenza, however, have undergone an important evolution since the start of the twenty-first century. Originally developed exclusively around intergovernmental collaboration in the 1950s, they have since become far more complex, reflecting a more interconnected, globalised reality. The focus of this chapter is to examine how pandemic influenza governance arrangements have changed over the past hundred years (and how they have not); the norms and ideas influencing preparedness; and the various actors, institutions, and resources that have been brought to bear in this critical area of public policy. The chapter concludes with an analysis of what these changes signify for the future of pandemic influenza governance.

532   Adam Kamradt-Scott

From Disaster to Discovery and Global Surveillance Influenza epidemics and pandemics have been regular features of human existence for the better part of one thousand years. Indeed, the first record of an influenza epidemic was documented to have adversely affected England, Germany, and Italy in 1173 ce (Cunha 2004). The first influenza ‘pandemic’ (defined as affecting two or more regions) appears to have occurred around 1510, having spread from northern Africa into the Middle East and then to Europe (Quinn 2008). Over the next four hundred years influenza epidemics and pandemics were recorded with such frequency that they were statistically evaluated to occur on average once every 19.8 years (Eichel 1922). Crucially, however, throughout this extensive history of human interaction with influenza the etiological agent responsible—a virus—remained undiscovered until the start of the twentieth century, with various explanatory theories ranging from the wrath of the gods to cosmological events and foul-smelling mists (or ‘miasma’) (Patterson 1986). The 1918 Spanish influenza pandemic remains to this day one of the four most significant epidemiological events in recorded human history. This one event, which spanned approximately an eighteen-month period around the end of World War I, resulted in the death of an estimated forty million people worldwide. The case fatality ratio (number of deaths divided by the number of infections), at 2.5 percent, was comparatively high compared to seasonal influenza (Taubenberger 2006), but critically, it is important to appreciate that the vast majority of people infected—some 97.5 percent globally—actually survived. During the 1918 pandemic a number of farmers had noted that a similar illness had appeared in pigs, and this observation then prompted a group of scientists to investigate whether a correlation existed (Smith, Andrewes, and Laidlaw 1933). In 1933 it was discovered that a virus was responsible for causing influenza, and that influenza did indeed have the ability to move between different species (i.e., it was zoonotic). As a direct consequence of the severe morbidity and mortality inflicted by the 1918 Spanish flu, public perceptions regarding the danger posed by the disease shifted markedly. For a time influenza became known as a ‘war disease’ (Francis 1947, 10), prompting the US military in 1941 to establish the Armed Forces Epidemiological Board to undertake research and development into influenza vaccines even as World War II raged in Europe (Hoyt 2006). These efforts were replicated across a variety of countries, including the Soviet Union, the United Kingdom, Australia, Argentina, and Canada, amongst others (Watterson and Kamradt-Scott 2016). In the wake of World War II, work on influenza vaccines shifted to the civilian sector, concentrated in a small number of high-income countries. Concern about a repeat of what had happened in 1918 nevertheless remained high, and in 1946, when the decision was taken to establish a new universal health agency in the form of the World Health Organization, one of the first tasks assigned to the Interim Commission of the WHO was to institute a new programme to monitor and study the virus.

Politics of Pandemic Influenza Preparedness   533 The commission initiated its work the following year by establishing the World Influenza Centre in 1947 in London, with the threefold objective of planning against the emergence of future pandemics; developing control methods to limit their impact when they did occur; and reducing adverse economic impacts (Payne 1953). In 1950 the third World Health Assembly (WHA)—the supreme decision-making body of the WHO— approved the creation of the Expert Committee on Influenza to provide specialist advice. The committee met for the first (and only) time in 1952, when it was decided to establish the Global Influenza Surveillance Network (GISN). The GISN’s primary function was to identify and trace the circulating strains of influenza, which it accomplished through progressively building a worldwide network of national influenza laboratories that would openly share the information they gathered with WHO reference laboratories (now labeled ‘WHO Collaborating Centres’). In 1952 an initial forty laboratories joined the GISN (Jensen and Hogan 1958), but indicating the level of concern that continued to exist about a potential repeat of 1918, by 1977 the network had expanded to some ninety-eight laboratories in seventy countries (Pereira 1979). A related function of the GISN was to provide assistance to the WHO’s member states in responding to influenza outbreaks, epidemics, and pandemics when they arose. The GISN was put to the test soon after its creation with the 1957 Asian flu pandemic. This event proved significant for two specific reasons, the first of which was that the virus caused approximately two million fatalities worldwide. Although substantially less than the 1918 Spanish flu pandemic, the 1957 Asian flu pandemic nevertheless caused considerable anxiety. The outbreak started in February 1957 in central China—one of the few countries that was not part of the GISN at the time—before spreading to Hong Kong, Manila, Singapore, and Japan, where samples of the virus were isolated. The data collected by Singapore and Japan were then shared with the WHO Collaborating Centres in London, Washington, DC, and Melbourne, which confirmed that the strain of the virus was novel. The WHO was then officially notified on May 23, 1957, about the presence of a novel influenza virus, but by this stage the virus had already begun to circulate widely via sea routes, with cases being reported from Indonesia to Manila and from Moscow to the Persian Gulf (Payne 1958; Langmuir 1961; Tognotti 2013). Over the following months the virus continued to spread internationally, reaching its peak in the Northern Hemisphere in the closing months of 1957 before gradually lessening throughout 1958. Whilst officially the number of deaths attributed to the pandemic was two million, in several countries, such as India and China, no record was made of the level of human morbidity and mortality, leaving many to speculate that the actual number of deaths was much higher (Quinn 2008). The second reason the 1957 influenza pandemic proved so significant was also arguably the only positive feature of the crisis; namely, it generated overwhelming evidence of the effectiveness of influenza vaccines in saving lives. Prior to the 1957 influenza pandemic, the scientific community was divided on the utility of vaccines, with various clinical trials offering mixed results. As a direct consequence of the spread of the 1957 virus, however, several governments, including those of the United States and the United Kingdom, instituted widespread influenza vaccination campaigns. The evidence

534   Adam Kamradt-Scott gathered from these campaigns definitively revealed the utility of vaccination, and since then vaccination has become recognised as the cornerstone of pandemic preparedness. To that end, the GISN increasingly began to share the data it gathered on circulating viral strains with pharmaceutical manufacturers to facilitate the production of influenza vaccines. This strategy proved particularly beneficial when the Hong Kong flu pandemic commenced in 1968. The 1968 influenza pandemic reportedly again began in China, but given that external relations with the Communist state had deteriorated even further since the late 1950s, the virus was not detected until it reached Hong Kong and Singapore (Kilbourne 2006; Quinn 2008). From Hong Kong the virus then continued to spread around Asia before being carried to the United States by US Marines returning from Vietnam. By the winter of 1968–1969 it had spread to Europe (Tagnotti 2013). The WHO officially notified governments that a pandemic was under way on August 16, 1968, and by mid-September— based on the experience of the 1957 pandemic—laboratories in the United States started work on developing a new pandemic-specific vaccine. Vaccination campaigns were then able to officially commence just two months later, on November 19, though the virus ‘had largely spent itself [in the United States] by the end of 1968’ (Hillman 1969, 623). This reportedly resulted in less domestic uptake of the vaccine, but the upshot of less interest in vaccination by US citizens was that the vaccines were then available to be utilised in parts of Europe and the Southern Hemisphere, where the pandemic was still unfolding (Hillman 1969). The collective experience of both the 1957 and 1968 pandemics conclusively revealed that influenza vaccines were effective in reducing human morbidity and mortality. As a result, a number of governments in high-income countries (HICs)—where the majority of vaccine manufacturers were located—focused their efforts over the next few decades on ensuring greater vaccine yield in faster time frames (Kamradt-Scott 2013). Increased recognition of the utility of antiviral medications as a second line of defense added to the influenza pharmaceutical ‘arsenal’ (Glezen 1996; Mendel and Sidwell 1998), but the ability to produce pandemic-specific influenza vaccines—which, crucially, relied on seasonal influenza vaccine manufacturing capacity—remained the core capability that many Western governments were keen to maintain. Importantly, however, the apparent success of influenza vaccines in reducing human sickness and death had an unanticipated and converse impact on international pandemic preparedness policy and practise. For decades the primary concern driving international collaboration had been the possibility that the 1918 Spanish flu pandemic would be repeated. Whilst a number of influenza experts periodically attempted to highlight the ongoing hazard of an influenza pandemic (WHO 1988; Webster 1994), for most HICs that maintained influenza vaccine manufacturing capacity, the risk of 1918 being revisited perceptibly lessened. Instead, throughout the latter half of the twentieth century influenza became increasingly viewed as a controllable disease that was most appropriately addressed by individual governments, ideally through vaccination campaigns that had been verified by biomedical knowledge and techniques such as clinical trials (Hota and McGeer 2007). The consequence of the lack of interest in collective action

Politics of Pandemic Influenza Preparedness   535 approaches by wealthier governments was a concomitant reduction in influenza-related funding. Disturbingly, this culminated in a situation in which when the 1997 outbreak of H5N1 influenza occurred in Hong Kong, reigniting fears that another influenza pandemic was imminent, the influenza division of the WHO had been reduced to just one full-time staff member (Kamradt-Scott 2012).

A New Era of Awareness and Vigilance The 1997 H5N1 outbreak proved a timely wake-up call about the threat of pandemic influenza. From the mid-1990s a number of government-based entities such as the US Institute of Medicine produced reports and other documents that underscored the menace posed by ‘emerging and re-emerging infectious diseases’ in an increasingly interconnected, globalised world (Lederberg 1996; Morens and Fauci 2012). Within this context, prominent public health officials had been warning that the world was ‘overdue’ for another influenza pandemic; thus when the 1997 H5N1 outbreak occurred, killing six of the eighteen people who became infected, anxiety rapidly grew that another pandemic was imminent. Whilst the controversial action of Hong Kong’s then health minister, Margaret Chan, in ordering the culling of the territory’s entire domestic poultry population was credited with having prevented a pandemic (MacPhail 2009), in hindsight it is now clear that the virus had already spread to wild bird populations, which carried the virus farther afield, eventually seeding H5N1 outbreaks amongst birds and humans in early 2003. Nonetheless, the 1997 outbreak prompted HICs to again devote attention and resources to the disease, and with renewed funding (and more staff), the WHO subsequently released its first official guidelines on pandemic preparedness in 1999 (WHO 1999). With the release of the inaugural pandemic influenza guidelines in 1999, several key global governance institutions, such as the World Bank, the IMF, and the UN, progressively joined the WHO in advocating that governments strengthen their preparedness. In 2003 the emergence of the Severe Acute Respiratory Syndrome (SARS) virus again elevated concerns that a pandemic was imminent. Yet whereas the coronavirus that caused SARS was rapidly contained (within four months of spreading internationally), the H5N1 virus, which had reappeared in China at the same time as SARS, was not so easily suppressed (Heymann and Rodier 2004; Uyeki 2008). Over the next few years multiple outbreaks of H5N1 occurred in Southeast Asia before spreading to the Middle East, Africa, and parts of Europe (Fauci 2006). The spread of H5N1 did not culminate in a pandemic, however, because the virus has—at least to date—failed to achieve effective human-to-human transmission, instead only infecting people who came into close contact with diseased birds (Uyeki 2008). Nevertheless, between 2003 and 2009 anxiety remained high that H5N1 would instigate a new pandemic, and based on

536   Adam Kamradt-Scott the advice of key global governance institutions, many governments sought to protect their populations through stockpiling antiviral medications and gaining access to influenza vaccines. Perversely, the demand for H5N1 influenza vaccines grew to such an extent that it inadvertently fractured the WHO’s GISN. Confronted with a growing number of H5N1related cases, in 2006 Indonesia’s president authorised the then health minister, Siti Fadilah Supari, to purchase a stockpile of H5N1-specific vaccines. Whilst several pharmaceutical manufacturers indicated they would be prepared to sign an advance ­purchase agreement (APA) with the Indonesian government to supply the requested vaccines, they also indicated that Indonesia would only receive its vaccines after other APA agreements had been filled (Kamradt-Scott and Lee 2011). Since Indonesia was the country with the highest number of H5N1-related fatalities, this response understandably infuriated the Indonesian authorities. When several related infringements related to the GISN’s virus-sharing arrangements also came to light, Supari announced in January 2007 that Indonesia would cease sharing samples of the H5N1 virus with the WHO’s GISN, claiming ‘viral sovereignty’ (Sedyaningsih et al. 2008). Indonesia’s controversial decision was condemned by some as effectively holding the world to ransom (Fidler 2008), but it garnered support from several other low-income countries (LICs) that also were struggling to access vaccine stocks (Fedson 2009). Indeed, whilst Indonesia was the only country to publicly announce it had ceased sharing influenza virus samples, and commentators concluded Supari’s decision was possibly motivated more by domestic political ambitions (Hameiri 2014), a number of countries reportedly considered following Indonesia’s lead. In response, the WHO convened a series of intergovernmental sessions throughout 2007 and 2008 in an attempt to find a diplomatic solution. When the initial meetings failed to arrive at a consensus, a more formal intergovernmental open-ended working group (OEWG) was established. Between 2010 and 2011 the OEWG met formally three times in addition to holding a series of consultation meetings with civil society organisations. Concurrent with these meetings, Indonesia pursued its claims of ‘viral sovereignty’ through the Convention on Biological Diversity conference in an attempt to strengthen its negotiating position within the OEWG meetings. In May 2011 the 64th WHA endorsed a new agreement— the 2011 Pandemic Influenza Preparedness Framework (PIPF) (Krishnamurthy and Herder 2013). The 2011 PIPF has substantially altered the nature of the WHO’s GISN, transforming it from a network exclusively funded by governments into a new public-private partnership. The GISN has also been renamed the Global Influenza Surveillance and Response System, or GISRS. Under the new agreement pharmaceutical manufacturers are no ­longer permitted to access data and biological samples on circulating virus strains to develop influenza vaccines without committing to ‘benefit-sharing’ arrangements that include, for instance, providing a percentage of influenza vaccines at heavily discounted prices. Other ‘benefits’ include such measures as technology transfers and improved access to diagnostic reagents and influenza test kits—resources that many LICs previously struggled to obtain. Pharmaceutical companies that seek to access the data and

Politics of Pandemic Influenza Preparedness   537 biological samples must also contribute to the operating costs of the reformed network, collectively contributing 50 percent of the network’s expenses. The division of payments amongst companies is purportedly ‘based on transparency and equity, based on their nature and capacities’ (WHO 2011, 18). Importantly, however, for an agreement that is explicitly limited to ‘the sharing of H5N1 and other influenza viruses with human pandemic potential’ (WHO 2011, 8), it has nevertheless encountered a number of implementation challenges. For instance, despite the fact that since 2012 private industry has been expected to contribute half the network’s operating costs, as the WHO secretariat noted in 2017, ‘not all companies pay their contributions by the expected deadline’, reportedly impeding capacity building (WHO 2017a, 18). Similarly, due to ongoing human resource limitations, for more than half a decade the WHO secretariat has been compelled to focus on negotiating the Standard Material Transfer Agreement 2, which facilitates delivery of ‘benefit’ products (e.g., vaccines, reagents) in a pandemic with only the larger pharmaceutical manufacturers (WHO 2017a, 59–60). This has meant, however, that small to medium companies have avoided entering into formal agreements with the WHO even though they may still be accessing—and financially benefitting from— GISRS biological materials. Moreover, it has been discovered that even laboratories that have signed agreements have not consistently utilised the Influenza Virus Traceability Mechanism, which tracks the sharing of GISRS biological materials and triggers the PIPF ‘benefit sharing’ process (WHO 2017a, 14). In short, due to a variety of issues, the reformed GISRS is still not operating as envisaged. By contrast, one of the programmes that has potentially exceeded expectations is the Global Action Plan (GAP) for Influenza Vaccines. The GAP was launched in 2006 with the aim of improving global influenza vaccine manufacturing capacity, which at the time was limited to approximately 1.5 billion doses per annum. Further, the entire influenza vaccine manufacturing capacity was located in HICs. The GAP explicitly sought to redress this by encouraging technology transfers and investment in low- and middle-income country (LMIC) vaccine manufacturing capacity, and by November 2016—in testament to efforts undertaken by the WHO and other partners—global vaccine manufacturing capacity had increased to an estimated 6.4 billion doses per year. Some fourteen new vaccine manufacturers had also been established in middle-income countries, reducing the world’s reliance on highly industrialised countries’ manufacturing capacity (WHO 2016). Although these achievements fall short of the GAP’s 10-billiondose target, it nevertheless has substantially increased the international community’s preparedness for the next influenza pandemic. Whilst work was under way to reform the GISN and anxiety remained high about the threat of another pandemic, prompting investment in the GAP, the first pandemic of the twenty-first century began in March 2009 in Mexico. Intriguingly, however, it was not the much-feared H5N1 virus that proved to be the responsible etiological agent, but instead a novel strain of H1N1 usually found in pigs. In mid-March 2009 an unusually high number of influenza-like illnesses were identified by the Mexican health authorities at a time when seasonal outbreaks were expected to be declining. In response, the Mexican Directorate General of Epidemiology ordered that surveillance for acute

538   Adam Kamradt-Scott respiratory diseases be heightened, and over the first ten days in April nongovernmental and government-based agencies reported an outbreak of influenza-like illness in La Gloria, Veracruz, that had reportedly affected a large proportion of the local inhabitants (WHO 2009a; Brown 2009; Shkabatur 2011). Under a trilateral agreement amongst the United States, Mexico, and Canada, clinical specimens collected from patients were sent to the US Centers for Disease Control and Prevention (CDC) in Atlanta and the National Microbiology Laboratory of the Public Health Agency of Canada for testing. Confirmation that these samples were of a novel strain of influenza A (H1N1) came in late April, but by this time the virus had not only spread to Mexico City but also internationally to the United States and Canada (WHO 2009a). By June 1, 2009, the WHO had received confirmed reports of H1N1 cases in sixty-four countries, prompting the organisation to officially declare on June 11, 2009, the first pandemic of the twenty-first century (WHO 2009b). Compared to previous pandemics, the severity of the 2009 H1N1 influenza pandemic initially appeared far less significant, provoking questions about whether the WHO had been unduly influenced to declare a pandemic. Three investigations—two external and one internal—were subsequently launched into the WHO’s decision-making processes and response, but in handing down their findings all three concluded that the WHO had not been pressured into making its determination. When the WHO director general officially declared the pandemic over on August 10, 2010, a total of 18,449 fatalities had been formally attributed to the H1N1 virus (WHO 2010). It was later estimated, however, that the number of deaths directly attributable to the virus globally was more likely between 123,000 and 203,000, and that the number of deaths arising from H1N1-related complications increased the overall human morbidity to 400,000 (Simonsen et al. 2013). Whilst the 2009 H1N1 virus was thus far less virulent than pandemics of the twentieth century, it nonetheless proved to be a significant global event and worthy of the WHO’s description of a ‘pandemic’. In the aftermath of the 2009 H1N1 pandemic, the wider international community was beset by what has been described as ‘pandemic fatigue’. This ‘fatigue’, which refers to a generalised reluctance to even discuss pandemic-related issues or topics (Dumiak 2012), persisted for several years and was compounded by the 2008 financial crisis, which discouraged further investment in pandemic preparedness (Brahmbhatt and Jonas 2015). As a phenomenon, however, it proved particularly problematic, given that in the wake of the H1N1 pandemic, several recommendations for reforming the WHO and creating new rapid response mechanisms for responding to health crises had been ignored— mechanisms that in the wake of the 2014 West African Ebola outbreak were re-examined, endorsed, and finally, actioned (McInnes 2015; Gostin et al. 2016). In implementing these reforms, however, pandemic preparedness has been increasingly devolved from the WHO to include other global actors not traditionally associated with health, let alone pandemic influenza preparedness. Indeed, since 2005 several prominent institutions and actors, such as the IMF, the World Bank, UNICEF, and more recently the Gates Foundation, have been actively engaged in strengthening global pandemic preparedness. The form of these institutions’

Politics of Pandemic Influenza Preparedness   539 interventions has varied, but a common theme—consistent with the WHO—has been encouraging countries to gain ready access to and/or stockpile influenza vaccines and antiviral medications to help protect their respective populations (IMF 2006; UNSIC and World Bank 2010). In October 2014, due to the failure of the international community to respond appropriately to the 2014 West African Ebola outbreak, the World Bank escalated its commitment by announcing plans to establish a ‘pandemic emergency facility’ to act as an insurance mechanism, whereby investors pay a premium that is then drawn upon to assist vulnerable countries in the event of an unanticipated crisis (Ross, Crowe, and Tyndall 2015). This facility was formally launched in May 2016 (World Bank 2016). A similar high-level intervention by the Gates Foundation that linked with other partners (including the Wellcome Trust, Germany, Japan, and Norway) witnessed the launch of the Coalition for Epidemic Preparedness Innovations (CEPI) in January 2017, which is designed to facilitate research and development into new vaccines for diseases with pandemic potential, including influenza (Moon et al. 2017; Gellin and Qadri 2016). Whilst some commentators have interpreted the rise of these ‘nontraditional’ actors as evidence of the ever-diminishing authority of the WHO (Lidén 2014), it must also be accepted that strengthening global pandemic preparedness was never intended to be the sole responsibility of one organisation. Pandemic influenza is, and is likely for some time to remain, an existential threat that requires collective action to mitigate. Admittedly, whilst the international network created in 1952 to address the threat of influenza pandemics was in dire need of reform by the start of the new millennium, the fact that the GISRS has only recently been augmented by other institutions arguably reflects decades of neglect rather than a failure of the WHO’s systems per se. In fact, as the preceding narrative outlines, public awareness and government commitment to addressing the threat of influenza pandemics has varied widely over the past century, from periods of intense anxiety that culminated in considerable resource allocations to overt lack of interest. Within this situation, the WHO as an institution has remained central, as have various norms, ideas, and values that have shaped the public policy response to this disease.

The Norms and Ideas Shaping Pandemic Policy Central to pandemic influenza policy and practise over the previous century has been avoiding a repeat of 1918. The Spanish flu pandemic continues to remain one of the most devastating epidemiological events in recorded human history (Walters 1978), and the risk that it may be repeated—and conceivably made worse as a consequence of g­ lobalisation— has exercised pandemic planners and policymakers for decades. In this respect, the spectre of 1918 has loomed large, and fear has proven to be a powerful motivating force,

540   Adam Kamradt-Scott driving forward not only influenza-related science but also policy decisions aimed at preventing a repeat. Within this historical context the primary focus has been on averting excessive human morbidity and mortality. Given that seasonal influenza epidemics generally result in a small proportion of lives lost, most medical professionals (and therefore policymakers) accept that the disease will kill some people despite their best efforts (Graham-Rowe 2011). In most HICs, however, since the 1950s and the discovery of the efficacy of influenza vaccines, considerable emphasis has been placed on vaccinating the most vulnerable population groups, traditionally those immunocompromised individuals at either end of the life spectrum. Biomedical knowledge, techniques, and technologies have thus remained central to influenza-related policy since the early twentieth century, and the influence of biomedicine in shaping pandemic preparedness policy has continued to grow and solidify over time. Even so, as highlighted later in this article, the field has also been extensively shaped by a variety of other competing ideas and normative agendas, resulting in political contestation over the most appropriate way to deal with the issue. Prior to discussing the norms and ideas that have shaped pandemic policy over the past century, it is important to note a particular feature that has customarily informed pandemic planning and preparedness policy, one that has now been potentially invalidated. As noted previously, the 1918 pandemic resulted in an overall global case fatality ratio of approximately 2.5 percent. This meant that the vast majority of people infected with the Spanish flu virus went on to make a full recovery. Yet in subsequent pandemic planning and preparedness decision-making, it has often been assumed that in order for an influenza virus to achieve effective human-to-human transmission—thereby creating the potential for a pandemic—the virulence of the virus would diminish to the extent that the case fatality ratio would not exceed that of the 1918 Spanish flu virus (Morens et al. 2010). Put another way, public health professionals and pandemic policymakers have traditionally viewed the 1918 Spanish flu pandemic as the ‘worst case scenario’ that they need to prepare for (Moxnes and Albert Christophensen 2008). In 2011 experiments conducted by two distinct groups of scientists who manipulated the H5N1 avian influenza virus raised the possibility that an airborne strain of influenza could emerge naturally that may infect humans and retain its current case fatality ratio in excess of 50 percent (Herfst et al. 2012; Imai et al. 2012). Whilst controversy raged over whether the scientists should have been permitted to conduct and then publish their research (Herfst, Osterhaus, and Fouchier 2012), the arguably more important discovery that an influenza pandemic capable of killing more than 2.5 percent of those infected worldwide could emerge naturally—and the existential threat that virus represents— has yet to sufficiently permeate international preparedness and planning. The catastrophic nature of such a development defies all contemporary planning scenarios, including those of the WHO and of countries with the most advanced healthcare ­systems (e.g., WHO 2017b). Although this research arguably warrants further attention and consideration by policymakers, historically other issues have dominated the influenza policy sphere.

Politics of Pandemic Influenza Preparedness   541 As previously noted, the centrality of biomedical knowledge, techniques, processes, and interventions to the control of influenza was evident from the inception of the WHO’s influenza programme in 1947. Biomedical evidence derived from clinical ­trials, for instance, was used in 1952 to explain why vaccination was not—at that time— recommended as an effective clinical intervention. By 1958, however, the clinical ­evidence derived from multiple vaccination trials conducted throughout the 1957 Asian flu pandemic permitted the WHO to definitively declare influenza vaccination as effective in reducing human morbidity and mortality. Since that time subsequent data generated through biomedical techniques have ensured vaccination has remained the ‘cornerstone’ of pandemic influenza preparedness. In this regard, the utilisation of scientifically generated clinical data driving medical knowledge and informing health-related policy is not especially new (Pope 2003), but following the introduction and codification of evidence-based medicine (EBM) practises in the mid-1990s, demand for ‘evidence’ to inform pandemic influenza policy has grown even stronger. Associated with this emphasis on technical scientific data has been the idea that such information is apolitical because it is objectively (‘scientifically’) acquired. Originally developed in Canada in the early 1990s, EBM has been progressively, extensively integrated into contemporary medical practise worldwide, instructing and informing the discipline of biomedicine along a series of core principles. These principles—that decisions are based on the best available evidence, that the problem determines the nature and source of evidence to be obtained, that epidemiological and biostatistical ways of thinking provide the best evidence, that conclusions are only useful if they assist in managing patients or healthcare decisions, and that performance should be constantly evaluated—assist adherents of EBM to categorise and stratify all modes of scientific inquiry and knowledge into distinct ‘levels of evidence’ (Davidoff et al. 1995). Within this system, systematic literature reviews drawing on randomised controlled trials (RCTs) that assess the efficacy of therapeutic (e.g., drug-based and surgical) interventions are classified as the ‘gold standard’ of evidence, followed closely by meta-analyses (systematic literature reviews that use quantitative methods to summarise the results of trials). The lowest category of evidence is expert opinion (Sackett and Rosenberg 1995). Within pandemic influenza preparedness and planning, EBM and evidence-based policy have now assumed preeminent status, with policymakers consistently framing their justifications for specific policy decisions on the ‘evidence’. One of the most prominent examples of EBM techniques informing and validating specific policy responses relates to the importance now attached to accessing influenza vaccines and antivirals. In 2009, for example, within a matter of days following the announcement of the H1N1 epidemic in Mexico, attention had shifted to the capacity of pharmaceutical companies to manufacture vaccines and the shortfall that would ensue due to global demand (Cohen and Enserink 2009). Soon thereafter pressure began to mount on those same companies to convert from producing seasonal influenza vaccines to a pandemic-specific version, even though it was accepted that this might result in unintended deaths due to shortages in seasonal vaccine availability (Collin et al. 2009). The importance of

542   Adam Kamradt-Scott these pharmaceutical interventions, which had been validated through EBM-related techniques, was further manifested when it was revealed that of the estimated US$1.48 billion needed to support the ninety-five least-resourced countries to respond adequately to the H1N1 pandemic, some US$1.14 billion (77 percent) was allocated to purchasing ‘H1N1 vaccines and other medicines’ (UNSIC and World Bank 2010, 30). As a method that advances apolitical ‘objective’ data, EBM has become so compelling that other fields have sought to either co-opt its techniques or emphasise their own capabilities in generating equivalent statistical data, to gain comparable political influence in shaping policy decisions. For example, even at the launch of the World Influenza Centre in 1947, it was recognised that influenza pandemics could have a devastating impact on not only national economies but also international trade. In this regard, the economic consequences of a widespread influenza pandemic have long been recognised. Especially since the late 1990s, however, a series of econometric studies examining the potential impacts on national productivity, social cohesiveness, and economic functioning have increasingly been used to evaluate mitigation strategies (such as vaccination programmes), justify policy decisions, and further emphasise the need for pandemic planning (Meltzer et al. 1999; Gust et al. 2001). As time passed, various government bodies increasingly combined EBM and economic analyses—such as ‘cost-benefit analysis’ techniques—in determining their planning and policy priorities for influenza (Nichol 2001; Belsey 2009). Similar arguments have been used to justify the creation of the World Bank’s new Pandemic Emergency Financing Facility, which aims to help countries become ‘better prepared for and able to respond to pandemics as well as [the international community’s] ability to handle the next pandemic on a global level,’ largely through offsetting the economic losses that would otherwise ensue (World Bank 2017). This trend has continued to such an extent that especially when it comes to  pandemic influenza preparedness policy, EBM and econometrics are often now inseparably entwined. Indeed, it has now become commonplace to fuse cost-benefit analyses with ­evidence-based medical interventions to rationalise pandemic-related policies. Studies are now habitually produced that use mathematical modeling and statistical inference to scrutinise pandemic influenza prevention and containment strategies and also draw on evidence-based data of specific medical interventions (e.g., vaccination, stockpiling antiviral medications) to justify or invalidate particular policy decisions (Ferguson et al. 2006). Whilst attention has often focused on pharmaceutical-based interventions that can be more readily quantified through EBM techniques such as RCTs (Balicer et al. 2005), these same strategies have been expanded recently in an attempt to quantify nonpharmaceutical or social-distancing measures such as school closures, measures that historically have been characterised by a ‘lack of evidence’ (Cauchemez et al. 2009, 473). The extension of these methods thus represents a new phase in evidence-based decision-making whereby a combination of ideas is used strategically to determine ­policy directions. A third and closely aligned concept that has become increasingly observable in pandemic influenza preparedness policy has been ‘security’. As previously noted, for a time

Politics of Pandemic Influenza Preparedness   543 after the 1918 Spanish flu pandemic influenza was openly described and considered a ‘war disease,’ to the extent that during World War II the US military created a dedicated influenza unit. With the commencement of the Cold War, more traditional security issues overshadowed the security implications of a widespread pandemic; however, by the mid-1990s and the emergence of the ‘human security’ agenda, threats to human health arising from emerging and re-emerging infectious diseases once again gained prominence. The ‘securitisation’ of pandemic influenza commenced in earnest following the 1997 H5N1 outbreak in Hong Kong, eventually culminating in the WHO officially declaring pandemic influenza to be ‘the most feared security threat’ just ten years later (Kamradt-Scott and McInnes 2012). Security-themed arguments have since been deployed extensively to highlight the menace posed by pandemic influenza, ranging from those that emphasise the threat to individual health and well-being, to the adverse impacts on national economies and social functioning, to the wider international state system as a whole (Garrett 2005; Enemark 2009; Elbe 2011). Amongst the security-based claims can be found statistically derived data pertaining to the potential numbers of lives lost in the form of pandemic fatality predictions, as well as various disaster scenarios of damage inflicted on the global economy. These trends have encouraged the development of a policy narrative that emphasises the all-encompassing catastrophic nature of an influenza pandemic which, ‘when’ it eventuates will not only result in large numbers of physical deaths but also cause severe economic, social, and conceivably political calamity. In sum, especially since the start of the twenty-first century there has been a functional conflation of EBM, economic, and security-constructed agendas influencing and directly informing global pandemic influenza preparedness policy. In fact, whereas pandemic influenza policy remained largely within the purview of the WHO throughout the second half of the twentieth century, since the start of the new millennium a diverse range of actors have entered the policy sphere. The entrance of these actors (many unconventional as health actors) has necessitated a political shift, or evolution, in the governance of pandemic influenza, moving it further away from being perceived as simply a biomedical issue. In so doing, these actors have added further legitimacy to the three dominant themes shaping pandemic influenza policy, either through emphasising one particular idea or by blending the ideas within their own policy guidance. For instance, whereas institutions such as the IMF have produced a number of policy documents that focus explicitly on the economic impacts arising from an influenza pandemic (IMF 2006), other entities such as the World Bank and the International Working Group on Financing Preparedness (IWGFP) have sought to seamlessly meld EBM-derived data regarding the threat to human health and well-being with economic and security concerns to argue for increased investment in pandemic preparedness (UNSIC and World Bank 2010; IWGFP 2017). As a result, economic, EBM, and security ideas are now firmly entrenched within pandemic influenza policy development. Intriguingly, whereas a number of other health policy fields have been actively shaped by the concept of human rights (Shiffman 2009; McInnes and Lee 2012), pandemic influenza policy has remained substantively devoid of such arguments. The most closely affiliated conceptualisation of ‘rights’ entering pandemic influenza policy discourse

544   Adam Kamradt-Scott arose in 2007, following Indonesia’s announcement that it would cease sharing influenza virus samples with the WHO’s GISN. Indonesia’s health minister argued for a reform of the existing virus-sharing system, in part, on the principle of ‘equity’—that all countries deserved access to life-saving influenza vaccines (Supari 2008, 83). Importantly, however, neither Indonesia nor the countries that diplomatically supported Indonesia’s position throughout the OEWG meetings sought to extend the rights-based argument beyond this particular context. As a consequence, the PIPF has remained assiduously narrowly focused, pertaining only to the sharing of influenza viruses with pandemic potential, and whilst improved access to medicines remains a contentious issue within the broader global health movement, notions of ‘human rights’ have failed to resonate within contemporary pandemic influenza governance arrangements. More broadly, the politics surrounding pandemic influenza has contributed to some significant transformations in global health. The ‘threat’ this particular disease poses has become so accentuated that it has obliged governments to place a very strong emphasis on developing and maintaining robust disease surveillance capacities and regularly report the technical data derived from those activities to the WHO. In so doing, however, it has furthered a disjuncture between global health objectives and national sovereignty. More specifically, since the late 1990s HICs have been at the forefront of encouraging the international community (and particularly LICs) to become better prepared for the next influenza pandemic. Yet whilst HICs have ostensibly sought to emphasise the ‘utilitarian benefits of cooperation’ in strengthening disease surveillance capacities (Katz and Fischer 2010, 8), their actions have been widely interpreted as self-motivated, even ‘knowingly blind to the issue of inequalities within or between countries’—that is, more about protecting ‘the West from the rest’ (Quinn and Kumar 2014, 270; Rushton 2011). Concurrent with this development, the emphasis placed on the global, collective nature of the ‘threat’ has in turn encouraged countries to place considerable importance on securing access to pharmaceutical stockpiles to protect their populations, thereby not only generating a further dichotomy between the ‘haves’ and ‘have-nots’ but also starkly juxtaposing global, shared vulnerability with national interests, security, and sovereignty.

Conclusion It is a common refrain amongst public health professionals and policymakers that another influenza pandemic ‘is not a matter of if, but when’. Even with tremendous medical advances, the creation of a dedicated international surveillance network, and quadrupling global vaccine manufacturing capacity since the start of the new millennium, the menace of another influenza pandemic wreaking widespread human suffering and severe economic disruption remains. This is principally because the influenza virus is prone to mutation, and the ease with which the virus moves amongst a number of species makes it a poor candidate for global eradication. Since the late 1950s the best defence

Politics of Pandemic Influenza Preparedness   545 continues to be vaccines, but ensuring they are effective against the specific pandemic strain takes time, often months, meaning that lives may be lost in the interim. Added to this, although global vaccine manufacturing capacity has been substantially improved since 2006 due to increased investment and technology transfers to LMICs, it nevertheless remains constrained. Measures have been taken to improve equitable access to vaccines via initiatives such as the 2011 PIPF and GAP, but these too are limited in scope. As this chapter has sought to highlight, the governance arrangements surrounding influenza have a long pedigree within international relations. Established at the end of World War II, the global influenza surveillance network progressively expanded its international reach, gathering biomedical knowledge and evidence on measures that might assist in preventing a repeat of the devastating 1918 Spanish flu pandemic. Over time the network continued to grow, influenced and shaped by the emergence of the EBM movement and recognition that pandemics could cause widespread social and economic disruption, eventually prompting their identification as a threat to the state system as much as to individual health and well-being. In 2007 the network suffered a crisis of confidence following Indonesia’s decision to cease sharing H5N1 avian influenza virus samples, citing several breaches of trust. Four years and a series of high-level diplomatic negotiations later, a new public-private partnership and framework for cooperation emerged. Although only time and another influenza pandemic will tell, the international community can only hope that the revised pandemic influenza system is up to the challenge. In the interim, however, the field of pandemic influenza public policy will remain one of competing ideas, priorities, and political agendas. As this chapter has highlighted, biomedical knowledge, later encapsulated and promoted as apolitical, technical ‘evidence’; economic considerations; and security arguments have powerfully shaped the structures and actors involved in addressing the risk of another influenza pandemic. These agendas and competing worldviews have evolved and been forced to adapt over decades, punctuated by periods of both hypervigilance and profound apathy. Moreover, the proposed solutions for dealing with the hazard—namely pharmaceutical interventions—acutely highlight global disparities between wealthy HICs and their less economically robust counterparts. In short, the politics of pandemic influenza serves as a microcosm of global health politics more broadly, with, unsurprisingly, all the commensurate challenges that represents.

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chapter 28

The Gl oba l Politics of HI V a n d A IDS Alan Whiteside

Global health politics is a new field of study. One of the most significant moments in its emergence was the World Bank’s World Development Report 1993: Investing in Health. This report recognized the importance of health for economic growth and, ultimately, development. It made policymakers, especially economists, wake up to the fact that health is crucial for the well-being of nations and led to increased research and thinking on the importance of health.1 While the World Bank’s report may have been a tipping point (in the written record), the emergence of global health politics as an area of study and its increasing importance owe a great deal to the appearance of HIV in the 1980s and the rapid growth in AIDS cases in the 1990s. The debates about access to treatment, whose responsibility it is to provide the resources, and the importance of prevention will be significant issues in health politics for decades to come. The importance of AIDS therefore is not simply the numbers of people who have died and will die from this ­syndrome, but because it was a harbinger of current global health debates and foreshadowed the issues of the new disease outbreaks the world is facing, such as the 2014–2015 outbreak of Ebola in West Africa and the 2016 outbreak of Zika in South and Central America. The disease we know as acquired immune syndrome (AIDS) is caused by the human immunodeficiency virus (HIV). It is a zoonotic infection that crossed from primates into humans in Africa. The first cases in humans may have occurred over a hundred years ago, but the extensive silent spread of HIV only began in the 1970s, then picked up speed in the 1980s, when it was increasingly seen outside Africa. This chapter tracks the intertwined epidemiologic and political history of the disease, from its emergence, to being seen as a global crisis, to the current status of being located primarily in particular regions and communities. It notes that many of the battles fought in the field of AIDS have spilled over into other areas, and that the analysis surrounding the disease has helped us understand the broader determinants of health and well-being.

552   Alan Whiteside The first AIDS cases were publicly reported in 1983, and the viral cause was isolated in 1983. In 1987 the name human immunodeficiency virus was confirmed. The current generally accepted term is ‘HIV and AIDS’ to distinguish between the periods when a person is infected and when he or she is ill. Treatment can mean a person will not progress beyond being HIV infected and so would never fall into the ‘AIDS’ category. At the time of publication (2017) there is still no cure for AIDS, and once people are HIV infected, they will remain so for the rest of their lives. Science has made huge progress, and infection is no longer a ‘death sentence’; people can be treated and live close to ­normal lives provided they adhere to the drugs. However, this has an economic and ­psychological price. One other point is to locate HIV and AIDS in public health thinking, as ultimately the epidemic is a public health issue. This fact was excellently captured in Davies et al. (2014), which identified four historical waves of public health development and which in turn helps us to understand the public health approaches to HIV and AIDS. The first wave (1830 to 1900) was structural: addressing physical and environmental conditions, ensuring clean water and sewerage disposal, legislating for food safety, and improved working conditions. The second wave (1890 to 1950) was biomedical and scientific advances: the first vaccine (smallpox) administered in 1796 and the United Kingdom’s 1853 Vaccination Act, which made immunization for smallpox compulsory for infants by the age of three months. By the end of the last century vaccines were lowering morbidity and mortality, especially among children. This was one of the reasons for the misguided optimism that an HIV vaccine would be quickly developed. The third wave (1940 to 1980) was clinical and scientific. There was understanding of causes of disease, and treatments were developed. Alexander Fleming identified the first antibacterial medicine, penicillin, in 1928. There were significant discoveries of new drugs of different classes for management of bacterial and viral infections. Rapid advances in cancer treatment included drugs, radiation, and surgery. The fourth wave began in 1960 with examination of the social determinants of health, and understanding ill health generally has roots in economic and social factors. In 2005 the World Health Organization (WHO) established the Commission on Social Determinants of Health (CSDH) to address the social factors leading to ill health and health inequities. Its report was issued in July 2008. It implicitly built on the work of Freire, Illich, and Wilkinson.2 Most recently, Angus Deaton has pioneered new directions of thinking, especially with regard to equity (Deaton 2013). Ultimately the spread of HIV has its roots in economic and social determinants, including poverty, gendered dimensions of disease, and inequality. Davies and colleagues (2014) argue that the fifth wave will be ‘a culture for health’. In this environment health should be the norm, it should be valued and incentivized, healthy choices should be the default, and unhealthy activities should be actively discouraged. This might have application in the rich world; it is less clear how people in developing nations will be able to respond. If the culture for health becomes the norm, it will have far-reaching implications for the culture of global health. Health is not simply a technical subject, and the history of and response to AIDS show this clearly. We have evidence and interventions, but putting them in place requires

Global Politics of HIV and AIDS   553 ­ olitical will. AIDS has driven global health architecture, led to the creation of new p institutions, and changed health politics. Unfortunately, global attention spans are limited, and gains need to be consolidated.

The Emergence of AIDS In 1980 the world seemed an increasingly healthy and happy place. In the ‘developing’ nations life expectancy was on the rise, and infant, child, and maternal mortality were decreasing. Major advances in science and medicine had paid off in the developed world, where the idea of an outbreak of an uncontrollable epidemic seemed the stuff of science fiction and Hollywood. The baby boomers were coming of age, having grown up in an increasingly (materially) rich and peaceful world. The last major conflict involving a Western nation (in Vietnam, so a war ‘played away’ rather than at home) ended in 1975. In 1976 the United States celebrated two centuries of nationhood. The process of decolonization in Africa was almost complete: Zimbabwe gained independence in 1980, and the apartheid regime in South Africa was under increasing pressure. There was a particular optimism regarding global health, as in 1980 WHO announced that smallpox had been eradicated, the first disease to be eliminated by human efforts. It was against this backdrop that, on June 5, 1981, the first cases of the disease that was to be identified as AIDS were publicly reported. The news appeared in the Morbidity and Mortality Weekly Report (MMWR), issued by the Centers for Disease Control in Atlanta in the United States (CDC 1981). There were unexpected clusters of previously extremely rare diseases, such as pneumocystis carinii, a type of pneumonia, and Kaposi’s sarcoma, normally a slow-growing tumor. These infections manifested in exceptionally serious forms, and initially within a narrowly distinct risk group: young, homosexual men in large urban centers in the United States. It soon became apparent these illnesses were occurring in other definable groups: hemophiliacs, blood transfusion recipients, and intravenous drug users (IDUs). By 1982 cases were being seen in the partners and infants of those infected. Beyond North America there was news of similar diseases from Europe, Australia, New Zealand, Brazil, and Mexico. In Africa Zambian doctors recorded a significant increase in cases of Kaposi’s sarcoma. In Kinshasa there was an upsurge in patients with cryptococcosis, an unusual fungal infection. The Ugandan Ministry of Health was receiving reports of increased and unexpected deaths among young people in Lake Victoria fishing villages. Doctors across southern and eastern Africa puzzled over cases of unusual illness that were not responsive to their medical armamentarium. This became apparent in conversations with a number of doctors, particularly those posted to mission hospitals. They described early puzzling cases, which in hindsight they believed were AIDS patients. All these patients died. A colleague of this author’s, Dr Alex Coutinho, who graduated as a doctor in 1983, said in 2016: ‘It was back in 1982 when I saw my first case of HIV—even though I didn’t know what I was seeing—in Uganda, in the cancer wards. Then in the

554   Alan Whiteside next couple of years after that we started seeing a lot of people dying in the wards, and even some of my own friends getting this strange disease. It wasn’t until 1984 that we realized that this was HIV’ (Kresge 2016).

The Politics of Blame It was not immediately clear what the cause of the disease was, how it spread, and what treatments were effective or could be developed. Scientists agreed that the most likely origin was a virus and began hunting for it. In 1983 the virus was identified by the Institute Pasteur in France and called Lymphadenopathy-Associated Virus or LAV. In April 1984 in the United States the National Cancer Institute (NCI) isolated the virus and named it HTLV-III. This led to the first public international politicization when, to the annoyance of the French, Margaret Heckler, the US Secretary of the Department of Health and Human Services (DHHS), announced that the NCI was responsible for the scientific breakthrough that identified HIV. The agreed upon face-saving compromise was to say that French and US laboratories both discovered the cause of AIDS. Regardless of the science, the origin of AIDS was disputed and politicized. During the Cold War in 1983, the KGB in the USSR set up Operation INFEKTION, a disinformation campaign claiming that the United States had invented HIV as part of a biological weapons research project. The idea that HIV was a man-made creation became part of conspiracy theories that have persisted into the new millennium. A 2005 study by the RAND Corporation and Oregon State University found that ‘nearly 50 percent of African Americans thought AIDS was man-made, over 25 percent believed AIDS was a product of a government laboratory, 12 percent believed it was created and spread by the CIA, and 15 percent believed that AIDS was a form of genocide against black people’ (Wikipedia 2016). The way the origin of the epidemic was communicated led to outrage on the African continent. Scientists knew the virus came from primates: chimpanzees in the case of HIV 1 and sooty mangabey monkeys in the case of HIV 2. The most probable mode of transmission was blood during the butchering of ‘bush meat’. Instead of this being properly conveyed, it was seen as people engaging in dubious practices and led to denigration, and blame, suggesting, at worst, that Africans had sex with monkeys. This discourse was most damaging in southern Africa. An early lesson from the epidemic was that science needed to be communicated better. Indeed, three decades later, in the case of the 2014–2015 West African Ebola outbreak, that there are animal reservoirs was generally understood, demonstrating improved sharing of knowledge about zoonotic outbreaks.

The First Fifteen Years: 1981 to 1996 The initial response followed standard public health patterns. Once the routes of ­ transmission—blood, blood products, and body fluids—had been identified as sources

Global Politics of HIV and AIDS   555 of infection, interventions were put in place. Tests were developed to ensure blood safety, and there were massive public information campaigns. Remarkably, in the United Kingdom pressure from Norman Fowler, the then secretary of health and social security, resulted in the Conservative government of Margret Thatcher taking AIDS very seriously. The cabinet members overcame their distaste for perceived ‘promiscuous and immoral behaviors’, and every household received a leaflet with the message: ‘Don’t die of ignorance’ (Fowler 2014). The initial fears that HIV would spread, unchecked, through the sexually active populations in wealthy countries proved unfounded. It became apparent that there were ‘key populations’ of people at greater risk. These were primarily men who have sex with men (MSM) and IDUs, but in some places key populations included sex workers. In the United States, prevalence has been, and is, higher among African American communities than among other ethnic groups. Europe initially experienced a disproportionate number of cases among African immigrants. Remarkably, outside some of the more sensationalist press, there was little blame allocated or political capital made from the location of the disease.3 By December 1987, 71,751 actual cases of AIDS had been reported to WHO. Most were in the West, with 47,022 in the United States alone, reflecting the ability to identify and diagnose cases there. An estimated five to ten million people were living with HIV worldwide. Over the first fifteen years the number of infections grew rapidly. A number of high-profile people—including film star Rock Hudson, musician Freddy Mercury, and tennis champion Arthur Ashe—were diagnosed with and died of AIDS. In Eastern Europe the epidemic appeared among IDUs, and in the post-communist period it started to spread among the youth, especially drug users’ partners. There were few drugs available, and those that were first developed prolonged lives by only a matter of weeks or months. However, in retrospect it is evident there were prevention successes. Most immediate was the provision of safe blood and blood products. The simple measures of reducing numbers of sexual partners, not sharing needles or sterilizing them if they were shared, and using condoms in both heterosexual and homosexual intercourse were shown to work. In Uganda, which was both the worst affected African country and the first to be open about the epidemic, the ‘zero-grazing’ message was part of the panoply of interventions that slowed the spread of HIV; this meant don’t go looking for greener grass, effectively, ‘stick to one partner’. In Thailand the ‘100 percent condom use’ campaign in brothels meant the incidence of HIV and other sexually transmitted infections plummeted. In 1987 reported STD cases stood at about 225,000, and condom use was less than 20 percent among sex workers in Thailand. By 1995 condom use in commercial sex acts was over 90 percent, and the number of nationally reported SDT infections had fallen to fewer than 10,000 (Ainsworth and Over 1997). Uganda and Thailand are examples of countries where the epidemic had taken hold and prevention interventions brought new infections down. There were some countries where effective interventions meant HIV simply did not spread, although there seemed potential for it to do so. One often cited example is Senegal. Here the Programme National de Lutte contre le SIDA (National Programme for the Fight against AIDS),

556   Alan Whiteside established in 1986, included condom promotion, sentinel surveillance to determine the scope of the epidemic, confidential counseling and testing, education of sex workers, and integration of HIV into sex education. Its effectiveness was marked by involvement of religious and community leaders, including a partnership between healthcare ­providers and Muslim and Christian religious leaders. In the three countries cited above (and the developed world), political leaders recognized the threat to their people and societies and were able to grasp the nettle of dealing with a sexually transmitted disease. They were, however, the exceptions. Most resource poor countries relied on support from WHO’s Global Programme on AIDS, which mobilized ‘swat teams’ of doctors, epidemiologists, and health educators who came in for short periods, establishing short term programmes (STPs) and then medium term programmes (MTPs). This was in part because ministries of health were stretched, but perhaps more important, the epidemic was invisible; although HIV infections were spreading rapidly, there were few AIDS cases. In the West AIDS was politicized from the beginning. The gay populations were motivated, active, and organized. At the Third International AIDS Conference in Washington in 1987, there were demonstrations against the lack of political commitment, the slow processes in developing and approving treatment, and the reluctance of President Ronald Reagan to talk about or even acknowledge the existence of the epidemic. Even when Reagan mentioned HIV, he did not acknowledge the vulnerability of the gay population. The US government banned HIV-positive travelers from entering the country, citing both public health concerns and the potential financial burden on US health services. As a result the AIDS 1992 conference was moved from Boston to Amsterdam. This politicization, however, was successful because it meant that in general the best (albeit very limited) treatments were made available, there were continued prevention campaigns, and the disease remained high on the agenda. Some global opinion leaders were also quick to address the stigma associated with being HIV positive. Most notably, in 1987 Princess Diana was photographed shaking hands with an HIV positive man, although even then the photographer was asked not to show the man’s face lest he be stigmatized. The UNAIDS and WHO developed four epidemiological scenarios: • Low-level: HIV has not spread to significant levels in any subpopulation because networks of risk are diffuse. This is the entire developed world. • Concentrated: prevalence is high enough in one or more subpopulations, such as MSMs, (IDUs, and sex workers and clients, to maintain the epidemic, but the virus is not circulating in the general population. This includes parts of Asia, Eastern Europe, Latin America, the Middle East, and the Caribbean. • Generalized: HIV prevalence is 1–5 percent in pregnant women attending antenatal clinics. The presence of HIV among the general population is sufficient for sexual networking to drive the epidemic. In an epidemic with more than 5 percent adult prevalence, no sexually active person is ‘low risk’. The areas affected are parts of Africa and the Caribbean.

Global Politics of HIV and AIDS   557 • Hyper-endemic: HIV is above 15 percent in adults in the general population. There are extensive heterosexual, multiple concurrent partner relations with low and inconsistent condom use. All sexually active persons are at risk. The drivers include early sexual debut, multiple concurrent sexual partnerships, intergenerational sex, low acceptability of condom use, and biological cofactors such as low levels of male circumcision and the presence of sexually transmitted infections. There may be high levels of HIV-related stigma; gender-based violence, including sexual coercion; and gender inequality. This pattern is seen in eastern and southern Africa.

AIDS Comes of Age: 1996 to 2010 By the end of 1996 an estimated twenty-three million people were living with HIV, but significant progress was being made. That year the international community established the Joint United Nations Programme on AIDS (UNAIDS) in Geneva, partly a response to the unexpected inability of WHO to provide leadership, which was part of its mandate. Also in the same year, at the 11th International AIDS Conference in Vancouver, it was announced that using certain drugs in combination could bring down viral loads, restore health, and effectively allow people to lead normal lives. A standard treatment of triple therapy, using three different drugs, was developed. This did not eliminate the virus from a patient’s body; reservoirs of infection remained, and if treatment ceased, the virus quickly replicated. Moreover, the cost of the drugs was considerable, roughly $10,000 per patient per year. Initially dosing regimens were complex, with people having to take handfuls of drugs at specific set times, in some cases with food, in others on an empty stomach. Although treatment ushered in a new era for patients in the West, the number of infections continued to rise. It became apparent that the largest epidemics were in the resource-poor world, and that this was more than a health issue. In 1996 US president Bill Clinton issued a Presidential Decision Directive calling for a more focused policy on infectious diseases; AIDS was one of the reasons for this. In 2000 the US National Intelligence Council stated that AIDS was one of the diseases that would ‘complicate US and global security over the next 200 years’ (National Intelligence Council 2000). The growing realization of how significant the epidemic was globally was not limited to the United States; consequently the disease was increasingly politicized internationally (McInnes 2006). In January 2000 AIDS was discussed in a special session of the UN Security Council, where US vice president Al Gore said: ‘It [HIV] threatens not just individual citizens, but the very institutions that define and defend the character of a society. This disease weakens workforces and saps economic strength. AIDS strikes at teachers, and denies education to their students. It strikes at the military, and subverts the forces of order and peacekeeping’ (UNSC 2000). Six months later the Security Council passed Resolution 1308. This was primarily about voluntary HIV/AIDS testing

558   Alan Whiteside and counseling for troops deployed in peacekeeping. However, it stated that the spread of HIV and AIDS could have a ‘uniquely devastating impact’ on all sectors and levels of society and pose a risk to stability and security. At the meeting Peter Piot, the director of UNAIDS, said that ‘beating back the epidemic in Africa alone would cost $3 billion’ (UN 2000). AIDS had come of age: the first disease to be given this level of attention, being debated in the Security Council and resulting in specific resolution. Following the Security Council’s deliberations, there was a period of intense analysis of the potential disruptive impact of the epidemic. This was seen in the work of the US Bureau of the Census in particular, which produced extremely pessimistic population projections (US Bureau of the Census 2004). In addition, there was academic analysis. My early engagement with the epidemic meant I was among the first to write, admittedly speculatively, on the possible impact (e.g., Whiteside and FitzSimmons 1992). The bulk of the work on potential impacts, however, emerged in the 2000s. In hindsight it is apparent that HIV was not, as feared, a significant security or economic risk, although for infected individuals and their families, it remains devastating. Reasons for this ‘overstatement’ of potential impact were the lack of treatment, cost of drugs (which it was believed would remain prohibitively high), and apparently unstoppable spread of the virus in southern Africa. The theme of the 2000 International AIDS Conference, held in Durban, was ‘Breaking the Silence’. The silence identified by the organizers was around access to treatment and prevention and human rights. Despite progress, stigma and economic constraints remained. As it happened, but was not foreseen at the time the slogan was adopted, the political atmosphere was highly charged. South Africa was entering its ‘denial period’, in which President Thabo Mbeki argued, confusedly, that HIV did not exist, but if it did then it was not a killer virus, and (anyway) ARV treatments were ineffective and toxic. These attitudes were greeted with disbelief by most scientists and health professionals, as well as some senior government and political figures.4 Observers have not definitively understood the underlying issues that led to Mbeki taking this stance; it may have been caused by the stigma of a sexually transmitted disease, irritation about Afro-pessimism, or personal issues. Unfortunately, in 2016 Mbeki reiterated his statements, asking why the virus behaved differently in Africa and the West and arguing that poverty and nutrition were critical (Mbeki 2016). This is analogous to trying to decide if the house was set on fire with matches or a lighter rather than dousing the flames. In 2002 research conducted by Tony Barnett and myself was published that introduced the ‘Jaipur paradigm’ (because the ideas emerged in a workshop in Jaipur in India), which explained some of the social factors influencing the spread of the disease. (Barnett and Whiteside 2002). The extent of the progression of the AIDS epidemic was at that time becoming apparent. It was clear that in some countries the focus of the disease would be among specific risk groups, while in others there was a generalized epidemic with exceptionally high levels of infection. Working with numerous international academic participants, development agencies, and others, we tried to understand why the epidemic was so bad in some areas and not others and if in turn this could be predicted. We had to understand the social and economic processes driving the epidemics

Global Politics of HIV and AIDS   559 and came up with four broad categories of country. The first were those with high social cohesion and high levels of wealth, including most of the developed countries. We argued that in these countries the spread of HIV would very rapidly be brought under control. This has proven to be the case at the national level across these countries. The second category was countries with high social cohesion but low wealth. Our view was that where there was such social cohesion, people were less likely to take risks that put themselves or others in harm’s way. The epidemics would be confined to specific, usually marginal groups such as IDUs, migrant workers, and mobile populations. The number of cases would rise but would be self-limiting. The examples were Cuba and Kerala state in India. The third case was where there was low social cohesion and low wealth. The epidemic levels would be higher than in the first two cases but would be limited by poverty and lack of access to resources. The countries we used as case studies were Ukraine and Uganda. The final group of countries included those where there was high (relative) wealth and low social cohesion. In this setting the levels of inequality are extreme. Here, we said, the epidemic would spread rapidly and extensively; our examples, Botswana and South Africa, showed that this was indeed the case. Crucially, we suggested that this lens of wealth and social cohesion could be applied not just to countries, but also to populations within them. This combination of politics, economics, and development allowed us to understand the epidemic and its evolution from an academic point of view. Academics aside, there was still the real challenge of responding to the disease at many levels. AIDS denialism and blaming key populations were widespread. In many African and Caribbean countries gay men were discriminated against and in some cases prosecuted. Intravenous drug use and sex work were criminalized. This made interventions complex. In addition there was a lack of concern for those who were infected. Access to treatment was not seen as a right for marginalized populations. Nevertheless, there was huge pressure from activists and some political leaders to bring down drug prices. Treatment in the developing world was a set combination of three less expensive drugs known as first line treatment. If these failed, and the patient fell sick or developed resistance, a more expensive second line was available. In some settings there was extremely costly third line treatment. At the Durban conference, South African judge and activist Edwin Cameron said of antiretroviral therapy (ART): ‘I can take these tablets, because on the salary I earn as a judge, I am able to afford their cost. . . . In this I exist as a living embodiment of the inequity of drug availability and access in Africa’ (Cameron 2000). As a result of the global pressure, prices fell. The Indian manufacturer of generic drugs Cipla announced in 2001 that it would sell first line triple therapy for US$350 per person per year. In 2001 the Doha Declaration on Agreement on TradeRelated Aspects of Intellectual Property Rights (TRIPS) and public health was adopted by World Trade Organization (WTO) member states. This created a situation in which cheap generic drugs would not be accessible in the countries where they were needed. Subsequently the TRIPS Council looked for solutions, including use of compulsory licensing. With increasing numbers of pharmaceutical companies, primarily from India, entering the market, the price of drugs continued to fall, and treatment regimens became simpler: the three active ingredients could be combined in a daily tablet.

560   Alan Whiteside The early years of the new millennium also saw the creation of two major initiatives to respond to the epidemic. First, following the January 2000 UN Security Council meeting, Secretary-General Kofi Annan called for the creation of a ‘global war chest’ to finance Millennium Development Goal (MDG) 6, which was to combat AIDS, tuberculosis, and malaria. As a result, in January 2002 the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) opened for business in Geneva with the clarion cry ‘Raise it, Spend it, Prove it’. Second, in 2003 Republican president George W. Bush pledged US$15 billion in establishing the President’s Emergency Plan for AIDS Relief (PEPFAR). Activists were surprised and delighted by the action of a conservative Republican president. In 2015 Bush said: ‘As President I found it morally unacceptable for the United States to stand aside while millions of people died from a disease we could treat. I also recognized that saving lives in Africa serves America’s strategic interests. When societies abroad are healthier and more prosperous they are more stable and secure’ (Bush 2015). PEPFAR has been reauthorized every five years since then. Concern about the epidemic in Africa also led Kofi Annan to convene, in 2003, the Commission on HIV/AIDS and Governance in Africa (CHGA) under the leadership of K. Y. Amoako, the executive secretary of the United Nations Economic Commission for Africa (ECA). I was a member of this commission, which reported in 2006. Our mandate was to (i) clarify the data on the impact of HIV/AIDS on state structures and economic development; and (ii) assist governments in consolidating the design and implementation of policies and programs that can help to govern the epidemic. It was clear from these deliberations that while resources were necessary, there needed to be national and international leadership. Nevertheless, during the early years of the new millennium the money flowed into HIV and AIDS, as shown in Figure 28.1. One of the key issues to which the chapter will return is future sources of funding. The political economy of the epidemic was neglected in times of plenty, when the challenge was how to spend resources rather than raise them. The financial crisis in 2008 led to a brief plateauing of funding, but soon it trended upward again. Although the SARS outbreak in 2002–2003 had demonstrated the potential of a pandemic to spread internationally (but fortunately it was brought under control), and an easily transmitted flu variant based on H5N1 (‘avian flu’) became a significant preoccupation during the first decade of the new millennium, AIDS remained the primary perceived infectious disease threat to the world until the Ebola outbreak, which began in March 2014 in West Africa. These diseases have shown global health is not as robust as was previously thought (and hoped). Ironically, the experience of the AIDS epidemic has been valuable in addressing the new challenges. It has helped in tracking and understanding the spread of disease, putting in place the science for prevention, and developing potential treatments and ultimately, cures.

Global Politics of HIV and AIDS   561 $25

US$ 21.7 billion

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Figure 28.1  Global funding for HIV and AIDS. Reproduced from Whiteside, Alan. HIV & AIDS: A Very Short Introduction. 2nd ed. New York: Oxford University Press, 2017. Source: Based on data taken from ‘No Money, No Results! New Estimates of Need,’ by Carlos Avila and Catherine Hankins, Joint United Nations Programme, with permission, and Kates et al., ‘Financing the Response to HIV in Low- and Middle-Income Countries: International Assistance from Donor Governments in 2012’ (The Henry J. Kaiser Family Foundation, September 2013), http://www.unaids.org/sites/default/files/en/media/unaids/ contentassets/documents/document/2013/09/20130923_KFF_UNAIDS_Financing.pdf.

The New Challenges: 2010 to 2017 and Beyond The science related to HIV continues to progress. Although there is not yet a cure, the drugs and drug combinations continue to advance. Currently a patient can take just one pill a day, and in the developed world, if the treatment fails there are different groupings of drugs that can be tried. With current trends, in the next few years there will be a oncea-week pill, then once a month, and ultimately drug delivery through implants. The advances in treatment mean that readdressing the prevention agenda is one of the major challenges we currently face. As with all health issues, it is better not to have the conditions in the first place: exercise and diet prevent diabetes, and not smoking dramatically reduces the risk of lung and other cancers, strokes, and heart attacks. Indeed, HIV is not an easy virus to transmit, and if the correct safeguards are in place they will prevent other, more straightforwardly communicated diseases such as hepatitis. Providing safe blood and blood products is generally second nature in healthcare settings, as are the universal precautions to prevent nosocomial transmission. Beyond blood there are a

562   Alan Whiteside range of other interventions that are tried and tested means of reducing likely exposure, including delaying sexual debut, sticking to one partner, using sterile needles in the case of IDUs, and using barrier methods to make sex safer (the condom is one of the best, and although female condoms have been developed, they are generally not popular). Medical male circumcision reduces the likelihood of infection for the man by about 60 percent, while the need for female-controlled methods resulted in the development of microbicides.5 The gendered nature of the epidemic has long been understood. Women are more likely to be infected than men. The female risk in receptive penile-vaginal intercourse is 8 per 10,000 exposures; for men with insertive penile-vaginal intercourse the risk is 4 per 10,000 exposures. Women face violence and a lack of empowerment when it comes to controlling sex. They are also the primary caregivers for the sick. In the past treatment was advocated for people with a CD4 count below a certain level: initially 200, then 350, then 500 cells/mm3. Most recently it has been established that a person on ART is up to 96 percent less likely to transmit HIV. This has led to a push to identify all infected people and put them on treatment as soon as possible. This new intervention is known as treatment-as-prevention (TasP). The International AIDS Conference held in Durban in 2016, however, sounded a note of caution about this approach (Iwuji et al. 2016). A study called ANRS12249 used the ‘test and treat’ strategy of testing people and offering ART immediately to those who were infected. It was expected and hoped that infected people would start taking drugs as soon as they learned they had HIV. The study found that only 47.5 percent of those infected sought care within the first six months of learning their status. Clearly more thought needs to go into treatment as prevention, as people have to be on therapy before their viral loads will fall. The idea of pre-exposure prophylaxis (PrEP) will be intensely debated over the next five years. If an uninfected individual takes the drugs, he or she will be protected from HIV transmission if a partner is infected. However, PrEP is not cheap—it can cost up to $13,000 per year—and one of the questions is who should pay for it (PrEP Facts 2016). The cost-benefit analysis economists do suggests that even if the infrastructure were in place, this is not a viable option for most countries, but there might be an argument for providing it for specific high-risk groups such as sex workers. This is a potential political minefield in rich countries and is unlikely to even be on the agenda elsewhere. In their recent discussion of the ethics of expanding access to cheaper, less-effective treatments, Persad and Emanual (2016) indirectly address these issues. They quote WHO director Gro Harlem Brundtland’s statement: ‘If services are to be provided for all then not all services can be provided. The most cost-effective services should be provided first’. They also note that provision of less-effective or more toxic interventions should be justified by the principles of utility, equality, and priority for those who are worst off. ‘Advocates and WHO are mistaken to demand that medical care provided in low-income and middle-income countries should be the same as in high-income countries. Instead, expansion of access to treatments that are effective, even if not the most effective, should be the standard in global health’ (Persad and Emanuel 2016, 933).

Global Politics of HIV and AIDS   563 The main political questions remain around funding HIV treatment. Key is what will be paid for and by whom and how prevention can be reprioritized. There are four streams of funding for HIV in low- and middle-income countries. First, in the past the bulk of funding came from donors; indeed in some countries (such as Malawi and the Ukraine) close to 100 percent of AIDS funding was from outside the national borders and hence ‘off budget’. This assumes, of course, that countries receive assistance because they need it; they have high levels of infection and or low capacity to respond. The reality is that the politics of aid are largely about the national influence and strategy of the donors. The politics of international funding suggest that the traditional donors will spend less partly because of their own financial issues but also due to fatigue with HIV and AIDS, as well as new needs including refugees, migrants, and environmental issues. International HIV assistance peaked at $8.6 billion in 2014 and fell to $7.5 billion in 2015. This aid is not expected to increase. However, there is one favored recipient, the GFATM. In September 2016 a replenishment pledging meeting was held in Montreal. The Fund set a target of $13 billion for the period 2017 to 2020, which was nearly reached at the meeting, and the staff were confident that it would be achieved in months or even weeks. The United States provides the most assistance to international health and HIV; it led the pledging in Montreal, with US$4.3 billion, approximately one-third of total funding. The United Kingdom’s $1.1 billion pounds was the second largest, but in terms of US dollars this was reduced by the decline in the value of the pound following the BREXIT vote. It remains to be seen what effects the Trump presidency will have on levels of US funding for international AIDS programmes. The political imperatives may change. International health funding is a political issue before it is an economic one. Persad and Emanuel echo others in saying that ‘the so-called golden age of growing global health assistance seems to have ended. . . . [E]ven if the funds needed were available, whether HIV/AIDS should be the top global health priority is unclear’ (2016, 934). The second and increasingly important source is domestic funding, which in 2012 surpassed international resources, a trend that will continue. However, in a country like Malawi, where the 2014 health expenditure per capita was just $29 (in 2014 spending), finding more than $100 per AIDS patient is a challenge, even if there were the staff and infrastructure needed. The third source is out-of-pocket payments by patients and their families. This is likely to increase in importance but raises issues of access and equity. Finally, there are contributions from the private sector especially through medical insurance schemes, although there have been attempts to mobilize funding more broadly. These have been and are likely to remain small. The role of innovative funding has been exhaustively analyzed. Ideas have included various types of taxes or levies. The best known example is the Zimbabwe AIDS levy, a 3 percent tax on the income of individuals, companies, and trusts that is paid into the Zimbabwe National AIDS Trust Fund (ZNATF) to finance aspects of the national HIV response. This has consistently raised millions of dollars but needs to be seen in the context of a collapsing economy. In June 2016 a report to the African Union, Innovative Domestic Financing for Health in Africa, concluded that ‘while innovative financing can

564   Alan Whiteside provide a steady, sustainable and equitable way of generating small amounts of ­additional resources for health, it should not be looked upon as the solution to Africa’s health financing resource challenges’ (Whiteside and Booth 2016). Where innovative mechanisms are able to create room in the budget for additional spending while not jeopardizing the fiscal stability of the economy, they should be implemented. However, innovative financing is not a panacea for domestic health financing. The mechanisms should be used only to complement traditional government revenue generation and as short-term solutions to funding needs while governments work to expand the tax base. General government taxation must therefore remain the priority, and ministries of finance and tax revenue authorities should be strengthened to collect and fund government activities from more progressive, equitable, and efficient general taxation.

Conclusion When looking at disease it is evident that wealth is one of the key determinants of people’s relative health. The classic study of civil servants in the United Kingdom showed that the higher ranks lived longer, healthier lives than their more junior colleagues (Marmot et al. 1978). This is part of the picture. The other is the issue of equality and how the society functions. The ‘World Happiness Report Update’ shows that the happiest five countries in the world are, in order, Denmark, Switzerland, Iceland, Norway and Finland (Helliwell, Huang, and Wang 2016). The countries with the worst epidemics fall in the last third of the list of 150. The economics of health—both causes and ‘cures’— should correctly be understood as political economics. By the turn of the millennium, it was believed that AIDS could have significant political impacts because of both the costs and who would be affected. It was believed there would be significant loss of leaders and voters, changing voting patterns, and disengagement and disillusionment with the political process at all levels. Moreover, in the early years of the epidemic there was evidence of increased mortality among politicians. The availability of ART changed this, and it is not surprising that politicians are among the first to access treatment. It is now clear that potential political impact is more limited. The Democracy in Africa Research Unit (DARU) at the University of Cape Town collaborates with the University of Michigan on the Afro-barometer project, which measures the social, political, and economic atmosphere through national public attitude surveys. These show that HIV and AIDS are not important as political or election issues. People’s primary problems are unemployment and poverty. In the first round of surveys, AIDS featured on the public agenda of only three southern African countries: 24 percent of Botswanans, 14 percent of Namibians, and 13 percent of South Africans cited HIV/AIDS as one of the top three problems facing the country. The question posed subsequently was: ‘In your opinion, what are the most important problems facing this country that government should address?’ Only in Botswana was AIDS seen as a significant

Global Politics of HIV and AIDS   565 issue, and by round six, which began in 2014, only 1.1 percent of those surveyed in Botswana mentioned it. It seems AIDS will not affect political processes in terms of votes. However, one clear result of the epidemic was activism. This began in the gay community in the United States. Horrified by illnesses and deaths among friends, they mobilized and in 1987 formed the AIDS Coalition to Unleash Power (ACT-UP), highlighting high drug prices and inadequate responses. In the United Kingdom the Terrence Higgins Trust was formed in 1982 to personalize and humanize AIDS. In the resource-poor world the Treatment Action Campaign (TAC) was launched (in South Africa) in 1998. In 2002 it was able to take the ANC government to court (and win) over government policies on access to medicines for pregnant women. In Uganda the AIDS Support Organization (TASO), established in 1987, grew into one of the major care-providing organizations. In Brazil activists brought prices of drugs down. One of the defining features of AIDS was the strengthening of civil society and grass-roots responses, which led to the development of numerous non-governmental organizations (NGOs) and social movements. These range from orphan support, to home-based care groups, to lobbying and advocacy movements pressing for reduced drug prices. AIDS does not unite people politically—there is no HIV party! It leads neither to societal collapse nor to dramatic change. While the direct links between AIDS and politics may be difficult to identify and measure, there are possible indirect ones. The epidemiology and economics of AIDS are well understood. We can count the money allocated and spent; we can see the establishment of new organizations: UNAIDS and the Global Fund are the prime examples. However, its politics remains obscure.

Notes 1. The growing literature on global health politics is discussed in the Introduction to this volume by McInnes and Lee. 2. Poalo Friere, a Brazilian thinker and activist, is best known for his book Pedagogy of the Oppressed, first published in English in 1970. Ivan Illich was born in Austria, studied for the priesthood, and worked in Mexico. He was known as a radical thinker and published Medical Nemesis in 1975. Richard Wilkinson’s classic Unhealthy Societies: The Affections of Inequality was published in 1996. 3. It is speculation, but the current political milieu in Europe might lead to a different response to HIV and other diseases in 2017 and beyond. Who gets infected is an epidemiologic and political issue, to which this chapter returns. 4. The best writing on the Mbeki era is in Nicoli Nattrass’s two books: Mortal Combat: AIDS Denialism and the Struggle for Antiretrovirals in South Africa (University of KwaZulu-Natal Press, 2007) and The AIDS Conspiracy: Science Fights Back (Columbia University Press, 2012). 5. A microbicide is a product inserted in the vagina that may be a gel or, as now being developed, a ring, from which the chemicals are released over time to kill the virus. So far the results have been disappointing, but this may be because women find it difficult to keep using the product.

566   Alan Whiteside

References Ainsworth, Martha, and Mead Over. 1997. ‘Confronting AIDS: Public Priorities in a Global Epidemic: A World Bank Policy Research Report.’ Washington, DC: The World Bank. http://documents.worldbank.org/curated/en/211211468779168446/Confronting -AIDS-public-priorities-in-a-global-epidemic. Barnett, Tony, and Alan Whiteside. 2002. AIDS in the 21st Century. New York: Palgrave Macmillan. Bush, George W. 2015. ‘Better Health Care in Africa Must Go Beyond HIV.’ Time, October 5. http://time.com/4065971/george-w-bushhealth-care-africa/. Cameron, Edwin. 2000. ‘First Jonathan Mann Memorial Lecture: The Deafening Silence of AIDS.’ Speech presented at the International AIDS Conference, Durban, South Africa, July 10. Centers for Disease control (CDC). 1981. ‘Epidemiologic Notes and Reports: Pneumocystis Pneumonia—Los Angeles.’ Morbidity and Mortality Weekly Report 30 (21): 1–3. https://www.cdc.gov/mmwr/preview/mmwrhtml/june_5.htm. Davies, Sally C., Eleanor Winpenny, Sarah Ball, Tom Fowler, Jennifer Rubin, and Ellen Nolte. 2014. ‘For Debate: A New Wave in Public Health Improvement.’ The Lancet 384 (9957): 1889–1895. doi:https://doi.org/10.1016/S0140-6736(13)62341-7. Deaton, Angus. 2013. The Great Escape: Health, Wealth, and the Origins of Inequality. Princeton, NJ: Princeton University Press. Fowler, Norman. 2014. AIDS: Don’t Die of Prejudice. London: Biteback Publishing. Helliwell, John  F., Haifang Huang, and Shun Wang; 2016. ‘Statistical Appendix for “The  Distribution of World Happiness”.’ Chapter 2, ‘World Happiness Report Update.’ http://worldhappiness.report/wp-content/uploads/sites/2/2016/03/StatisticalAppendix WHR2016.pdf. Iwuji, Collins  C., Joanna Orne-Gliemann, Joseph Larmarange, Nonhlanhla Okesola Frank Tanser, Rodolphe Thiebaut, Claire Rekacewicz, et al. 2016. ‘Uptake of Home-Based HIV Testing, Linkage to Care, and Community Attitudes about ART in Rural KwaZulu-Natal, South Africa: Descriptive Results from the First Phase of the ANRS 12249 TasP ClusterRandomised Trial.’ PLoS Medicine 13 (8). Kresge, Kristen J. 2016. ‘A Career Defined by AIDS.’ IAVI Report 20: 3. http://www.iavireport .org/vol-20-no-3-2016/1870-a-career-defined-by-aids. Marmot MG, Rose G, Shipley M, et al. 1978. Employment grade and coronary heart disease in British civil servants. J Epidemiol Community Health 32:244–249.Google Scholar 1002107. doi:10.1371/ journal.pmed.1002107. Mbeki, T. 2016. ‘A Brief Commentary on the Question of HIV & AIDS.’ Eyewitness News, March 7. http://ewn.co.za/2016/03/07/OPINION-Thabo-Mbeki-A-brief-commentary-on-the -question-of-HIV-and-Aids. McInnes, Colin. 2006. ‘HIV/AIDS and Security.’ International Affairs 82 (2): 315‒326. doi:10.1111/j.1468-2346.2006.00533.x. National Intelligence Council, 2000. ‘The Global Infectious Disease Threat and Its Implications for the United States’, Report JAN 2000 Washington D.C. Persad, Govind C., and Ezekiel J. Emanuel. 2016. ‘The Ethics of Expanding Access to Cheaper, Less Effective Treatments.’ The Lancet 388 (10047): 932–934. doi:http://dx.doi.org/10.1016/ S0140-6736(15)01025-9. PrEP Facts. 2016. ‘The Questions about PrEP.’ http://men.prepfacts.org/the-questions/.

Global Politics of HIV and AIDS   567 United Nations (UN). 2000. ‘Security Council, Adopting “Historic” Resolution 1308 (2000) on HIV/AIDS, Calls for Pre-deployment Testing, Counselling for Peacekeeping Personnel.’ http://www.un.org/press/en/2000/20000717.sc6890.doc.html. United Nations Security Council (UNSC). 2000. ‘Remarks as Prepared for Delivery by Vice President Al Gore, UN Security Council Session on AIDS in Africa.’ https:// clintonwhitehouse4.archives.gov/WH/EOP/OVP/speeches/unaid:health.html. US Census Bureau. 2004. The AIDS Pandemic in the 21st Century. International Population Reports WP/02-2. Washington, DC: U.S. Government Printing Office. Whiteside, Alan, and P. Booth. 2016. ‘Innovative Domestic Financing for Health in Africa: Documenting Best Practices and lessons Learnt in Innovative Domestic Financing for Health and Alignment of International Funding to National Priorities.’ Unpublished report. Whiteside, Alan, and David FitzSimons. 1992. The AIDS Epidemic: Economic, Political and Security Implications. London: Research Institute for the Study of Conflict and Terrorism. Wikipedia. 2016. “Operation INFEKTION.” https://en.wikipedia.org/wiki/Operation_ INFEKTION. World Bank. 1993. World Development Report 1993: Investing in Health. New York: Oxford University Press.

chapter 29

The Gl oba l Politics of N egl ected Tropica l Dise ase s Obijiofor Aginam

[A] fatal imbalance existed between the health needs of poor people in  developing countries and the lack of R&D to develop medicines to treat them. —Orbinski (2008, 366) The 17 diseases targeted by WHO share a common stranglehold on those populations left furthest behind by development: they perpetuate poverty. —WHO (2012)

Neglected tropical diseases (NTDs), according to the World Health Organization (WHO), are ‘a diverse group of diseases with distinct characteristics found mainly amongst the poorest populations of the world’ (WHO 2012, 13). More than one billion people live with the mortality and morbidity burdens of these diseases, mostly in the tropical and subtropical conditions of more than 140 countries. WHO estimates that NTDs cost developing economies billions of dollars annually, and the most vulnerable groups are the populations living in poverty, without adequate sanitation and in close contact with infectious vectors and domestic animals and livestock (WHO 2018, 2007). Sometimes referred to as ‘orphan diseases’ (KCE, Belgian Health Care Knowledge Centre 2009) because of their neglect by major global health actors and the lack of any significant commercial and economic investment in them, the prevalence of NTDs in developing and least-developed countries and their burdens on poor people and communities have perpetuated a global health apartheid—a world in which about 90 percent of the global research and development (R&D) budget is devoted to the diseases of the 10 percent of the world’s population in industrialised and wealthy countries (Santoro and

570   Obijiofor Aginam Gorrie 2005). Juxtaposed with comparable disparities between and amongst countries in the development discourse, Falk (1999, 13, 17) deployed the metaphor of ‘global apartheid’ to argue provocatively that: Several characteristics of the global political economy shape the tactics and aspirations of progressive social forces: extreme hierarchy and unevenness of circumstances, acute deprivation and mass misery amongst the poor; erosion of autonomy at the level of the state as a consequence of the play of non-territorial capital forces. . . . If these critical differences are appreciated, the global apartheid metaphor seems useful. It confronts the moral and political complacency of the North. . . . The metaphor of global apartheid, then, represents a warning as well as a provocative line of critique, suggesting the urgency of taking far more serious steps to overcome the North-South cleavage.

This chapter explores the global politics of NTDs by assessing their historical ‘neglect’ by Falk’s ‘non-territorial capital forces’, epitomised by the influential global pharmaceutical industry, as well as the lack of visibility of NTDs in major development paradigms in the 1990s and early years of the millennium, including their conspicuous omission from the Millennium Development Goals (MDGs). Given the attention and resources devoted to NTDs in recent years by WHO, donors, philanthropy, and civil society, this chapter assesses the emergent NTD policy architecture and concludes by interrogating whether, in the context of Agenda 2030 for sustainable development, the millions of people still affected by these diseases will be left behind by the advances in international development and global health. Notwithstanding the emergent interest by global health actors in NTDs, the realpolitik or ‘microbialpolitik’ of contemporary global health gov­ern­ance, driven by an ‘anarchical international system’ (Fidler 1999, 18–19; Fidler 2004, 248) that is ‘complicated and messy’ (Zacher and Keefe 2008, 135), has equally complicated the complex global politics of NTDs. This chapter argues that the global politics of NTDs oscillates between the Scylla of WHO’s vulnerabilities as an intergovernmental organisation whose mandate is shaped by the strategic interests of its most powerful member states and often lacking the resources to effectively tackle the most pressing global health issues, and the Charybdis of global public-private partnerships in which the private and corporate actors will likely not be incentivised enough to take bold action to tackle NTDs.

Fatal Imbalance: NTDs and the 10/90 Divide Global health scholarship is replete with literature on the ‘fatal imbalance’ between the health of the rich and poor across societies (Baxi 2010; Farmer 2001, 2005; Garrett 2000; Pogge 2002; Labonte et al. 2004; WHO 2001b). As Orbinski (2008, 366) argued, a fatal

Global Politics of Neglected Tropical Diseases   571 imbalance has always ‘existed between the health needs of poor people in developing countries and the lack of R&D to develop medicines to treat them’. In 2000 the Global Forum for Health Research published the widely cited 10/90 Report, which deplored the imbalance in global health research that largely ignored NTDs (Global Forum for Health Research 2000). Economic and financial incentives driven by profit maximisation have historically been the major motivation behind the R&D budget in the global pharmaceutical industry (‘t Hoen  2009; Santoro and Gorrie  2005). As Callahan & Wasunna (2006, p.192) observed: The much cited “10/90 divide”—with 90 percent of medical research going towards diseases for just 10 percent of the world population—shows the gross neglect of research for diseases afflicting the world’s majority poor. . . . The bottom line is that the developing world does not represent a profitable market for the international pharmaceutical industry. In effect, the industry is saying that, because of an inability to pay for them, or to properly distribute and monitor them, development of drugs for the diseases of poor countries is a financial loser.

The 10/90 gap in health-related R&D means that ‘many diseases that occur largely in the developing world amongst poor people are neglected and thus the diseases themselves thrive. Because of a virtual absence of drug R&D, millions continue to suffer and die from diseases such as malaria, TB, sleeping sickness (trypanosomiasis), Chagas disease, or leishmaniasis’ (Orbinski 2007, 33). The neglect of NTDs—as diseases of the poor—has led to their glaring invisibility in international development policy frameworks. NTDs were largely invisible in the Millennium Development Goals (MDGs), packaged to target socioeconomic issues affecting the poor. In the MDGs, NTDs were packaged amongst ‘other diseases’ without any express mention (Furst et al. 2017). In their concise historical overview of NTDs in global health policy, Furst et al. (2017) observed that the omission of NTDs in the MDGs was a [c]all to arms for the NTD stakeholders and a stimulus to join forces to gain a critical mass. Key arguments were the considerable geographical overlap of NTDs, the commonness of co-infections related to shared risk factors, their poverty-driven and poverty-promoting characteristics, and potential synergies in fighting them. The little resources devoted to NTDs in relation to their burden and the availability of comparatively cheap options for treatment and prevention further encouraged the coordination of specific efforts to address the NTDs and to develop the NTD brand.

The fifteen-year lifespan of the MDGs (2000–2015) substantially overlapped with WHO’s Global Plan to Combat Neglected Tropical Diseases 2008–2015. To what extent did the WHO Plan align with NTD stakeholders locally and globally to develop an innovative NTD brand?

572   Obijiofor Aginam

WHO’s Global Plan to Combat Neglected Tropical Diseases, 2008–2015 Adopted in 2007, the Global Plan was an ambitious policy framework to combat NTDs based on the vision that ‘NTDs and zoonoses are a devastating obstacle to human settlement and socioeconomic development of already impoverished communities’ (WHO 2007). The goal of the Global Plan was to ‘prevent, control, eliminate and eradicate NTDs and zoonoses’ by providing measures for the ‘prevention, early detection, diagnosis, treatment, control, elimination and eradication of NTDs and zoonoses that disproportionately affect poor and marginalised populations’ (WHO 2007). Anchored on several core public health principles, including the right to health enshrined in the WHO Constitution (WHO 2001a, 1)—‘the enjoyment of the highest attainable standard of health’ by every human being”—the Global Plan laid out nine strategic areas for action, including the urgent need for ‘partnerships and resource mobilisation’ (WHO 2007). Assessing the implementation of the Global Plan, it is arguable that whilst WHO may have succeeded in articulating the key challenges in NTD control, the organisation failed in its efforts to catalyse innovative partnerships to incentivise the pharmaceutical industry towards pragmatic NTD action. In a subsequent policy document, ‘Accelerating Work to Overcome the Global Impact of Neglected Tropical Diseases: A Roadmap for Implementation’ (WHO 2012), WHO listed fourteen ‘major donations of medicines for controlling neglected tropical diseases by the pharmaceutical industry’. Assessing the Roadmap, it is arguable that beyond charitable donations, the global politics and governance of NTDs should focus on aligning the strategies, skills, and strengths of the diverse and multiple actors for effective partnerships that address private sector interests, including concerns over pharmaceutical patents, without compromising the health needs of millions of poor people who live with the burdens of NTDs. Partnerships often require a delicate balance between private sector interests and public needs. Examples of innovative ideas include Medecins sans Frontieres’ (MSF)/Doctors without Borders’ launch of the not-for-profit Drugs for Neglected Diseases Initiative. According to Orbinski (2007, 35), this has created ‘new affordable treatments for diseases that primarily affect poor people in the developing world. The initiative began in 2003. . . . The goal is not to singularly assume the responsibility for neglected disease R&D, but to demonstrate that alternatives to the current system are possible, and to insist on political responsibility in achieving the needs-driven, equity-oriented global R&D agenda as a public responsibility’. This initiative offered a tactful policy pathway to navigate through the intellectual property (patent) highway. As ‘t Hoen (2009) observed, the patent policy of the Drugs for Neglected Diseases Initiative (DNDI) regards ‘drug research as a public good that should primarily lead to the advancement of health’. In addition to the proposals from civil society organisations

Global Politics of Neglected Tropical Diseases   573 such as MSF, in 2009 Novartis, a leading pharmaceutical corporate actor, proposed The Fund for Research in Neglected Tropical Diseases (FRiND) (Herrling  2008). FRiND was originally envisaged to become a dominant funder of neglected diseases research. Albeit ambitious in its original scope and coverage, this was subsequently scaled down because of donor fatigue from most stakeholders. Should WHO, as the intergovernmental institution with a mandate to coordinate international health work, take the lead in midwifing these types of innovative partnerships for each of the seventeen NTDs (see Table 29.1)? Is there any coherent synthesis between the ‘health as a public good’ argument and the postulation that intellectual property (patent) serves as an incentive for innovative private-sector-led ‘production’ of goods? An assessment of health as a ‘global public good’, however, is a complex intellectual endeavour (Smith et al. 2003; Kaul et al. 1999, 2003). In principle, public goods are characterised by two essential features: non-excludability (the benefits are unrestricted, and available to all), and non-rivalry in consumption (the consumption by one person does not limit consumption of the same good by others). Because most goods are private in nature, or at least in the case of medicines produced largely in the private domain by pharmaceutical companies, striking a balance between intellectual property and health as a public good is a daunting task. In 2001 the WHO Commission on Macroeconomics and Health tackled these tensions head on by recognising that the ‘production of new knowledge, especially through investments in research and development (R&D)’ is an important kind of public good (WHO 2001b, 77). Proposing a pragmatic approach, the commission (WHO 2001b, 77) persuasively argued: Since knowledge is ‘non-rival,’ meaning that the use of knowledge by one person does not diminish its availability for others, it makes sense for society to ensure that new knowledge is widely available and actually used. Yet if the fruits of R&D are freely available, profit-maximising firms will lack the incentive to invest in R&D in the first place. The pragmatic approach in balancing the need for availability of knowledge with the need for private incentives to invest in R&D is to combine two policy instruments: public financing of R&D in combination with patent protection for private investors in R&D.

Turning to R&D directed at diseases endemic in poor countries, the commission rightly observed that the ‘incentive mechanisms fail at both ends,’ for two reasons. First, the governments of poor countries would lack the funds to subsidise R&D. Second, patent protection carries little value when there is no significant market at the end of the R&D process. Because poor countries benefit from R&D when the rich also suffer from the same diseases, the commission distinguished amongst three types of diseases. Type I diseases are prevalent in both rich and poor countries, with large numbers of vulnerable populations in each. Type II diseases are incident in both rich and poor countries, but with a substantial proportion of the cases being in the poor countries. Type III diseases are those that are overwhelmingly or exclusively incident in the developing countries, such as African sleeping sickness (trypanosomiasis) and African river blindness (onchocerciasis)

Table 29.1  Neglected Tropical Diseases—Summary Disease

Description

Control & Treatment

Global Morbidity & Mortality

Dengue1

A mosquito-borne infection causing flu-like illness that may develop into severe dengue and cause lethal complications. Global incidence has grown due to urbanisation; half of the global population is at risk.

Control of mosquito vector to stop dengue spread is prioritised. Only symp­to­matic treatment available.

Estimated 390 million infections annually, with 3.9 billion at risk.

Prophylactic vaccine carries a risk of severe dengue with repeated infection and has yet to be implemented as a preventative measure.

Around 500,000 hospitalised each year due to severe dengue, with estimated 2.5% case fatality.

Rabies2

A preventable viral disease transmitted to humans through the bites of infected animals that is invariably fatal once symptoms develop.

Post-exposure prophylactic (PEP) vaccine and immunoglobulin exist but are not widely available or accessible. Average cost of rabies PEP is USD 40 in Africa and USD 49 in Asia. Mass dog vaccination (> 70% canine population) is also employed as a preventative measure.

> 15 million receive PEP worldwide annually. Predominantly affects the poor who live in remote rural areas. Estimated 59,000 deaths annually, 95% of which are in Asia and Africa.

Trachoma3

A chlamydial infection transmitted through direct contact with infectious eye or nasal discharge or through indirect contact with unsafe living conditions and hygiene practises, which left untreated causes irreversible corneal opacities and blindness.

Control of the disease is by elimination of the infectious agent through good sanitation and hygiene and access to clean water. Trachoma is treatable with antibiotic and corrective surgery (average cost USD 40). No vaccines available.

Estimated 2.2 million are visually impaired due to trachoma in Africa, Asia, Central and South America, and Australia; of which 1.2 million are blind. Women are at greater risk for blindness due to exposure as caregivers to adults and children infected with trachoma.

Buruli ulcer4

A debilitating mycobacterial skin infection causing severe destruction of the skin, bone, and soft tissue.

Early detection and treatment with antibiotics are vital to prevent permanent loss of functionality. No vaccines available.

In 2015, 2,037 new cases were reported from 13 countries; most patients are children under 15 years of age.

Yaws5

A chronic bacterial infection affecting mainly the skin and bone that can lead to disfigurement and disability.

As of 2015, > 46,000 cases reported No specific preventions besides promotworldwide. ing personal hygiene and health education. Early infection is treatable with antibiotics. No vaccines available.

Leprosy6

A complex disease caused by infection mainly of the skin, peripheral nerves, mucosa of the upper respiratory tract, and eyes.

Exact mechanism of transmission is not known; no specific preventative measures or vaccine available. Leprosy is treated using multi-drug antibiotic therapy similar to that for tuberculosis.

Global registered prevalence in 2015 was 176,176 cases.

Chagas disease7

A life-threatening illness transmitted to humans through contact with vector insects (triatomine bugs), ingestion of contaminated food, infected blood transfusions, congenital transmission, organ transplantation, or laboratory accidents.

Vector control and screening of blood product in endemic areas are crucial. Infection is treated with nifurtimox and benznidazole.

Estimated that 10,000 people die from Chagas disease annually; 25 million remain at risk.

Human African trypanosomiasis8 (sleeping sickness)

A parasitic infection spread by the bites of tsetse flies that is almost 100% fatal without prompt diagnosis and treatment to prevent the parasites invading the central nervous system.

Vector control and early treatment has been credited for the lower number of cases since the 2000s. WHO publicprivate partnership with Sanofi and Bayer was pivotal to this reduction.

Estimated number of cases since 2015 is < 20,000; estimated population at risk stands at 65 million people.

Leishmaniasis9

Disease transmitted through the bites of infected female sandflies that in its most severe (visceral) form attacks the internal organs and in its most prevalent (cutaneous) form causes face ulcers, disfiguring scars, and disability.

Vector control to prevent leishmaniasis is difficult because sandfly control requires complex environmental management and domestic sanitation. Leishmaniasis is treatable but often affects populations in remote areas with little to no healthcare access.

Estimated 700,000–1 million new cases annually, of which 50,000–90,000 are visceral leishmaniasis, with > 95% fatality rate if untreated.

Dracunculiasis10 (guinea-worm disease)

A nematode infection transmitted exclusively by drinking-water contaminated with parasite-infected water fleas.

Vector (water fleas) control has been effective in lowering the transmission of guinea worm.

21 cases reported in 2018.

(continued)

Table 29.1  Continued Disease

Description

Control & Treatment

Global Morbidity & Mortality

Echinococcosis11

Infection caused by the larval stages of tapeworms forming pathogenic cysts in humans and transmitted when ingesting eggs, most commonly shed in faeces of dogs and wild animals.

Deworming of sheep, canine, and other hosts is the most important method to lower transmission of Echinococcus tapeworm. Treatment is expensive and difficult; patients often suffer reduced quality of life even with treatment.

>1 million are affected by tapeworms at any given time, causing an estimated 19,700 deaths and 871,000 disability cases annually.

Foodborne trematodiases12

Infection acquired by consuming fish, vegetables, and crustaceans contaminated with larval parasites; clonorchiasis, opisthorchiasis, and fascioliasis are the main diseases. Flat worms affect organs such as liver, bile duct, and brain.

Improving sanitation and clean water access is necessary to interrupt the infection cycle. Preventative chemotherapy is available.

Estimated 2 million deaths and disabilities annually.

Lymphatic filariasis13

Infection transmitted by mosquitoes causing abnormal enlargement of limbs and genitals, from adult worms inhabiting and reproducing in the lymphatic system.

Control of mosquito vector is the primary preventative measure. Chemotherapy is available to eliminate microfilaria. Chronic manifestation often leads to disability and poor quality of life.

Estimated 36 million people live with the chronic manifestation of the infection.

Onchocerciasis14 (river blindness)

Infection transmitted by the bite of infected blackflies, causing severe itching and eye lesions as the adult worm produces larvae and leading to visual impairment and permanent blindness.

Control of blackfly vector is ­recommended to interrupt transmission. Chemotherapy is available.

Estimated 20.9 million are infected; of which 14.6 million have skin disease and 1.15 million suffer vision loss.

Schistosomiasis15

Trematode infections transmitted when larval forms released by freshwater snails penetrate human skin during contact with infested water. Chronic infection in children causes anaemia, stunts growth, and affects learning ability.

Control through improving access to clean water, safe sanitation, hygiene education, and vector control. Chemotherapy is available.

Estimated deaths range from 24,000 to 200,000 per year.

Soil-transmitted16 helminthiases

Mycetoma17

Nematode infections transmitted through soil contaminated by human faeces, causing anaemia, vitamin A deficiency, stunted growth, malnutrition, intestinal obstruction, and impaired development. Mycetoma is a chronic, progressively destructive inflammatory skin disease that usually affects the lower limbs. Infection is thought to be caused by the inoculation, through a thorn prick or skin damage, of fungi or bacteria into the subcutaneous tissue.

Approximately 1.5 billion infected at any Periodical deworming treatment, given time. improved sanitation and clean water access, and hygiene education are needed to control the infestation. Chemotherapy is available. Global health burden is unknown; endemic Treatment is often expensive and unsatisfactory, has many side effects, and in Asia, Latin America, Africa, and Europe. may require surgery. Footwear can protect against puncture wounds that lead to mycetoma, but may not be affordable for the poor in endemic regions.

https://www.who.int/en/news-room/fact-sheets/detail/dengue-and-severe-dengue. https://www.who.int/rabies/en/. 3 https://www.who.int/trachoma/en/. 4 https://afro.who.int/health-topics/buruli-ulcer. 5 https://www.who.int/en/news-room/fact-sheets/detail/yaws. 6 https://www.who.int/lep/en/. 7 https://www.who.int/chagas/en/. 8 https://www.who.int/news-room/fact-sheets/detail/trypanosomiasis-human-african-(sleeping-sickness). 9 https://www.who.int/news-room/fact-sheets/detail/leishmaniasis. 10 https://www.who.int/dracunculiasis/disease/en/. 11 https://www.who.int/news-room/fact-sheets/detail/echinococcosis. 12 https://www.who.int/news-room/fact-sheets/detail/foodborne-trematodiases. 13 https://www.who.int/news-room/fact-sheets/detail/lymphatic-filariasis. 14 https://www.who.int/news-room/fact-sheets/detail/onchocerciasis. 15 https://www.who.int/news-room/fact-sheets/detail/schistosomiasis. 16 https://www.who.int/news-room/fact-sheets/detail/soil-transmitted-helminth-infections. 17 https://www.who.int/news-room/fact-sheets/detail/mycetoma. 1 2

578   Obijiofor Aginam (WHO 2001b, 78). Type III diseases—the very neglected diseases—receive extremely little R&D and ‘essentially no commercially based R&D in the rich countries. When new technologies are developed, they are usually serendipitous, as when a veterinary medicine developed by Merck (ivermectin) proved to be effective in control of onchocerciasis in humans’ (WHO  2001b, 78). Proposing that WHO and the Global Forum for Health Research partner with the donor and research communities to ‘identify, on an ongoing basis, the high-priority areas of R&D for poor country disease conditions that are neglected by the international pharmaceutical sector’, the commission recommended that ‘at least $3.0 billion per year should be allocated to towards R&D directed at the health priorities of the world’s poor’ (WHO 2001b, 81). At the heart of the commission’s recommendations to incentivise R&D to target NTDs is the establishment of effective global public-private partnerships. WHO—since the 1990s—has accelerated the creation of these partnerships (Pinet 2003; Reich 2002), defined as collaborative relationships that ‘transcend national boundaries and bring together at least two parties, a corporation (or industry association) and an intergovernmental organisation, in order to achieve a health-creating goal on the basis of a mutually agreed and explicitly defined division of labour’ (Buse and Walt 2000, 549). Whilst the trend towards public-private partnerships in global health governance has demonstrated ‘possibilities for tackling problems that formerly seemed intractable, particularly those requiring increased research and development (R&D) on drugs and vaccines for diseases disproportionately affecting the poor’ (Buse and Waxman 2001, 748), the fundamental question underlying virtually all proposals on stimulating industrial research and development for NTDs is ‘who should pay?’ (Webber and Kremer 2001). Can industrialised countries underwrite the cost for poor countries? How could the scarce global resources be allocated towards R&D targeting neglected diseases? (Kettler and Modi 2001). To answer these questions satisfactorily would ensure that the world is not leaving millions of NTD-threatened people behind in the 2030 Agenda for sustainable development.

NTDs, SDGs, and ‘Leaving No One Behind’ In September 2015 world leaders adopted an ambitious set of seventeen sustainable development goals (SDGs) and 169 targets and indicators after a long and tortuous consultative process led by the United Nations. The SDGs, which succeeded the Millennium Development Goals, would guide the global development agenda until 2030. Influenced by the Report of the High-Level Panel established by the UN Secretary-General, the SDGs are driven by five large transformative concepts: leave no one behind; put sustainable development at the core; transform economies for jobs and inclusive growth; build peace and effective, open, and accountable institutions for all; and forge a new global partnership. Health is primarily anchored in SDG 3: ‘Ensure healthy lives and promote

Global Politics of Neglected Tropical Diseases   579 well-being for all at all ages’. One of the targets of SDG 3 is to ‘end epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases’. SDG 3, in conjunction with SDG 17 (‘Strengthen the means of implementation and revitalise the global partnership for sustainable development’), shapes the global politics of NTDs perplexingly. If a significant majority of millions of people who live with the mortality and morbidity burdens of neglected tropical diseases globally live in the world’s poorest countries, the visibility and firm anchorage of NTDs in Agenda 2030 raises the same complex questions that have preoccupied international relations scholars for decades. Since the contemporary international system is historically built on the Westphalian principles of sovereign statehood, do industrialised or rich countries have any obligation to commit financial resources towards the prevention, control, and eradication of NTDs in poor countries? The global politics of NTDs will not gain much traction if the dominant thinking remains that the international system is anarchical, and that the major driver of the foreign policy of the big powers within this anarchical system is the pursuit of strategic interests driven mainly by hard-core security and commercial issues. NTDs—a diverse group of seventeen diseases found mainly amongst the poorest populations in developing and least-developed countries—are serious humanitarian issues but not strategic enough to get the required attention from the rich countries. Conversely, it has been argued that ‘enlightened self-interest’ should be the cornerstone of global health policy in order to pursue the progressive realisation of the right to the ‘enjoyment of the highest attainable standard of health’ codified in 1946 by the Constitution of the World Health Organization. As Brundtland (2001) argued: Enlightened self-interest compels both industrialised country governments and private corporations to do what it takes to drastically reduce the current burden of disease in the developing world. To do so will be good for economic growth, be good for health and be good for the environment. Not only for the three billion people who have yet to benefit from the technological and economic revolution of the past fifty years—but for us all.

In addition to self-help and enlightened self-interest, tackling the burdens of NTDs in the developing world serves the agenda of humanitarianism, which is driven by a moral obligation on states to act in the interests of shared humanity. Humanitarianism has driven much of development policy (or at least the rhetoric of it) since the evolution of the post-1945 international system.

Conclusion WHO estimates that more than one billion people live with the burdens of NTDs in tropical and subtropical conditions in more than 140 developing and least-developed countries. NTDs cost developing economies billions of dollars annually, and the most

580   Obijiofor Aginam vulnerable groups are the populations living in poverty. Given the fatal imbalance between the health needs of poor people in developing countries and the lack of R&D to develop medicines to treat NTDs, there is an urgent need to incentivise the private/ corporate sector through public-private partnerships to invest more in these diseases. Whilst partnerships now abound in global health governance architecture, pertinent questions have been raised about the accountability, transparency, and effectiveness of global public-private partnerships. Since the 2030 Agenda for Sustainable Development with its seventeen SDGs is premised on the promise of ‘leaving no one behind’, the world owes a moral obligation to the one billion people affected by NTDs. Because these diseases are prevalent in the poor countries, their continued neglect amounts to banishing millions of impacted people to a penitentiary of poverty, thereby leaving them further behind in 2030 when the world takes stock of the successes and failures of the SDGs. The global politics of control of NTDs has been turbulent. The realpolitik of control and eradication of NTDs globally requires pragmatic leadership and a governance architecture that brings key public and private sector players together. Central to this gov­ern­ ance architecture is the urgent need to craft innovative incentives for sustainable R&D funding to target all aspects of NTD control. Although globalisation offers potential health benefits to all of humanity, the prevalence of NTDs in poor countries means that globalisation has not been a fair, humane, and equitable enterprise. As Nobel laureate Joshua Lederberg reminds us, ‘[T]he world is just one village. Our tolerance of disease in any place in the world is at our own peril’.

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Global Politics of Neglected Tropical Diseases   581 Furst, Thomas, Paola Salari, Laura Monzon Llamas, Peter Steinmann, Christopher Fitzpatrick, and Fabrizio Tediosi. 2017. ‘Global Health policy and Neglected Tropical Diseases: Then, Now, and in the Years to Come.’ PLOS 11 (9): e0005759. Garrett, Laurie. 2000. Betrayal of Trust: The Collapse of Global Public Health. New York: Hyperion. Global Forum for Health Research. 2000. The 10/90 Report on Health Research. Geneva: Global Forum for Health Research. Herrling, Paul  L. 2008. ‘Making Drugs Accessible to Poor Populations: A Funding Model.’ Global Forum Update on Research for Health (5): 152–155. Kaul, Inge, Pedro Conceicao, Katell Le Goulven, and Ronald U. Mendoza, eds. 2003. Providing Global Public Goods: Managing Globalization. New York: Oxford University Press. Kaul, Inge, Isabelle Grunberg, and Marc Stern, eds. 1999. Global Public Goods: International Cooperation in the 21st Century. New York: Oxford University Press. KCE, Belgian Health Care Knowledge Centre. 2009. Policies for Orphan Diseases and Orphan Drugs. Brussels: KCE. Kettler, Hannah E., and Rajiv Modi. 2001. ‘Building Local Research and Development Capacity for the Prevention and Cure of Neglected Diseases: The Case of India.’ Bulletin of the World Health Organization 79 (8): 742–747. Labonte, Ronald, Ted Schrecker, David Sanders, and Wilma Meeus. 2004. Fatal Indifference: The G8, Africa and Global Health. Cape Town: UCT Press. Orbinski, James. 2007. ‘Global Health, Social Movements, and Governance.’ In Governing Global Health: Challenge, Response, Innovation, edited by Andrew F. Cooper, John J. Kirton, and Ted Schrecker, 29–40. Aldershot, UK: Ashgate. Orbinski, James. 2008. An Imperfect Offering: Dispatches from the Medical Frontline. London: Rider. Pinet, Genevieve. 2003. ‘Global Partnerships: A Key Challenge and Opportunity for Implementation of International Health Law.’ Medicine and Law 22: 561–577. Pogge, Thomas W. 2002. ‘Responsibility for Poverty-Related Ill Health.’ Ethics and International Affairs (16): 72–79. Reich, Michael  R. ed. 2002. Public-Private Partnerships for Public Health. Cambridge, MA: Harvard. Santoro, Michael A., and Thomas M. Gorrie. 2005. Ethics and the Pharmaceutical Industry. New York: Cambridge University Press. Smith, Richard, Robert Beaglehole, David Woodward, and Nick Drager, eds. 2003. Global Public Goods for Health. New York: Oxford University Press. ‘t Hoen, Ellen F. M. 2009. The Global Politics of Pharmaceutical Monopoly Power. Diamen, The Netherlands: AMB Publishers. Webber, David, and Michael Kremer. 2001. ‘Perspectives on Stimulating Industrial Research and Development for Neglected Tropical Diseases.’ Bulletin of the World Health Organization 79 (8):735–741. World Health Organization (WHO). 2001a. Basic Documents. 43rd ed. Geneva: World Health Organization. World Health Organization (WHO). 2001b. Macroeconomics and Health: Investing in Health for Economic Development: Report of the Commission on Macroeconomics and Health. Geneva: World Health Organization. World Health Organization (WHO). 2007. ‘Global Plan to Combat Neglected Tropical Diseases, 2008–2015.’ http://apps.who.int/iris/bitstream/handle/10665/69708/WHO_CDS_ NTD_2007.3_eng.pdf;jsessionid=5D32A8BFFB6E23E8E99F2E33B5CBE4A7?sequence=1.

582   Obijiofor Aginam World Health Organization (WHO). 2012. ‘Accelerating Work to Overcome the Global Impact of Neglected Tropical Diseases: A Roadmap for Implementation; Executive Summary.’ http://apps.who.int/iris/bitstream/handle/10665/70809/WHO_HTM_NTD_2012.1_eng .pdf?sequence=1&isAllowed=y. World Health Organization (WHO). 2018. ‘Neglected Tropical Diseases.’ http://www.who.int /neglected_diseases/diseases/en/. Zacher, Mark W., and Tania J. Keefe. 2008. The Politics of Global Health Governance: United by Contagion. New York: Palgrave Macmillan.

chapter 30

The Politics of Gl oba l Vacci nation Policies Stuart Blume

In attempting to control, prevent, or eradicate infectious diseases, global health policy now relies on vaccination to a considerable extent. The effectiveness of vaccination has been shown repeatedly throughout a long history. Beginning with Edward Jenner’s use of cowpox to prevent smallpox at the end of the eighteenth century, this history ranges from Louis Pasteur’s and Robert Koch’s work a century or more ago, through advances in viral tissue culture methods that led to Salk’s (inactivated) and Sabin’s (live attenuated oral) polio vaccines in the mid-twentieth century, and most recently to conjugated and DNA vaccines. Alongside these remarkable scientific achievements has been a slow but steadily growing use of vaccines worldwide. This chapter discusses the global political factors shaping vaccination policy from the mid-nineteenth century onwards. Whilst the increasing use of vaccines over time may be understood as driven by profit seeking and market growth by the pharmaceutical industry, historical trends cannot be wholly explained by the role of commercial interests. Belief in the power of technology and in the viability of technical solutions to problems of (global) public health has been no less crucial. At the same time, global institutions have become increasingly authoritative in determining the deployment of vaccines (vaccination schedules), not necessarily with regard principally to the healthcare needs or priorities of national governments or populations. This chapter discusses the role of global politics in explaining these factors, how this situation has arisen, and what the implications are.

584   Stuart Blume

A New Tool for Public Health In the mid-nineteenth century, as public health was becoming a field of state action, vaccines were of minor importance. Depending upon what were thought to be the causes and modes of disease transmission, as well as political and administrative traditions, practises emphasised either sanitary measures or quarantine. Insofar as infectious disease was thought to be the result of contagion, restrictions on the cross-border movement of travellers, as well as goods that might harbour an infectious agent (e.g., bales of cotton or wool), made sense. Such measures, however, led to tensions with the business community, which perceived them as restrictions on the flow of trade, as well as with foreign governments, which suspected deliberate attempts to hinder their commercial interests (Baldwin 2005; Harrison 2012). One early benefit of microbiology, emerging as a new discipline at the time, was that it permitted late nineteenth-century scientists to establish whether a given individual, or a given bale of merchandise, was infected. This alleviated the need to use blanket quarantines. Soon afterwards, the same basic science was used to create what were to become some of public health’s most effective tools, including vaccines. The principle of vaccination was not new. In the late eighteenth century, Jenner had already established that infection with a mild pathogen (cowpox) offered protection against a related, but far more serious, one (smallpox). Thereafter, many countries began to vaccinate their populations against smallpox, and in many places smallpox vaccination was made compulsory. In England, for example, smallpox vaccination was made compulsory in 1853 and administered by the Boards of Guardians, responsible for administering the Poor Laws in local parishes. Here, as in many other countries, the element of compulsion backed by penalties led to controversy and protest. From a scientific perspective, for many years it was taken for granted that the use of a mild infection to protect against a more serious one was only feasible when two closely related conditions were involved. When Pasteur demonstrated that this was not necessary and that weakened (or ‘attenuated’) pathogens could work just as well, he pointed the way to key advances in health technologies. First, however, the bacterium responsible for each individual disease would need to be identified and cultured in the laboratory. Scientists turned their attention to the major diseases of the period: tuberculosis, diphtheria, cholera, and typhoid. By the time a diphtheria ‘antitoxin’ was developed, at the end of the nineteenth century, systems for administering and delivering smallpox vaccination were in place in many countries. Whilst these systems might have been deployed to administer the new diphtheria serum, they were not. This was not only because of the unpopularity of state-mandated vaccination. Despite the fact that diphtheria was a dangerous childhood disease, no one considered large-scale prophylactic vaccination against it. Instead, the serum was used in hospitals to treat young patients. It was not until after World War I, during which preventive vaccination of soldiers against typhoid (caused by Salmonella typhi) proved so successful, that prophylactic

Politics of Global Vaccination Policies   585 vaccination (other than against smallpox) began to gain credibility (Hooker and Bashford 2002; Lewis 1986). Vaccination against tuberculosis (TB) has had a similar history. Although the microbial cause of tuberculosis (tubercle bacillus) had been isolated by Robert Koch in 1882, many still died from the disease at the beginning of the twentieth century. The overcrowding caused by housing shortages and the undernutrition suffered by many during World War I facilitated its spread and exacerbated its effects. Despite years of research, the war was over before a vaccine with protective efficacy became available. When it did in the 1920s, some countries made the vaccine a cornerstone of their TB control efforts. Others, however, including Great Britain and the United States, did not. These variations in policy reflected diverging political assumptions and administrative practises. The BCG (Bacillus Calmette-Guérin) vaccine was developed by scientists Albert Calmette and Camille Guérin at the Pasteur Institute. The institute then made it freely available in France, where it came to be widely used. In Scandinavian countries, TB vaccination also found early champions, notably Johannes Holm, director of the Danish State Serum Institute (SSI), and Arvid Wallgren, professor of paediatrics at the University of Gothenburg. In both Denmark and Sweden, large-scale BCG vaccination began in 1927. In Britain, where scientists questioned the vaccine’s safety as well as its efficacy, vaccination was not adopted. British scepticism towards the BCG vaccine also had a moralising aspect. Looking at variations in TB mortality rates across districts of a city, observers were struck by how much higher rates were in poorer districts. During the 1920s this was not necessarily attributed to differences in the material and environmental conditions in which people lived. Medical Officers of Health were just as likely to blame lifestyle choices deemed to be misguidedly rooted in ignorance and carelessness (Bryder 1999). This led to the conclusion that people needed to be taught to take responsibility for their own health, learn the value of a healthy diet, and follow a lifestyle involving plenty of fresh air and exercise. Using an argument reminiscent of vaccination against the sexually transmitted human papilloma virus almost a century later, some claimed during the 1920s that the BCG vaccination would give people a false sense of security and reduce the incentive to change their behaviour. A further argument, presented by the chair of the British Ministry of Health’s Immunisation Committee (set up in 1931), was that the country already had a preventive policy (involving isolation), as well as a well-developed, sanatorium-based curative service. It was believed that introduction of BCG could interfere with the sanatoria, with which many TB specialists were professionally involved (Bryder 1988, 138–142). Vaccination against typhus, a bacterial disease caused by the Rickettsia bacteria, was also influenced by interests and ideology, embedded in administrative traditions, though under very different circumstances and without the moralising tone attached to TB vaccination. During the course of World War II, different typhus vaccines were developed in the United States, Vichy France, Poland, and Germany (Weindling 1996). In contrast to its scepticism towards BCG, the US government rapidly vaccinated its soldiers against typhus, to great effect. The British were more hesitant, whilst vaccination

586   Stuart Blume in Nazi Germany was hindered not only by scepticism, but also by rivalries between vaccine producers and branches of the armed forces.

Mass Vaccination after World War II The role of wartime conditions in facilitating the spread of infectious diseases and adding urgency to the search for effective public health interventions applied equally during World War II. Hostilities officially ended in 1945, but the health emergency created by the conflict continued long after. Central and Eastern Europe were devastated by bombing and foreign occupation, and large swathes of the surviving population were left displaced, homeless, and half-starved. Infectious disease control in the rest of the world, viewed by the League of Nations Health Organization during the 1920s as a problem for colonial powers, had received little attention during the war years (Worboys 2000). After 1945, with talk of decolonisation in the air, this attitude began to change (Worboys and Condrau 2010). It is in this context that practises concerning vaccination also began to change. At the 1949 Commonwealth and Empire Tuberculosis Conference, a number of delegates spoke in support of TB vaccination in the British colonies, where facilities were inadequate for large-scale treatment (Altink 2014). In Britain, too, there was a willingness to rethink BCG vaccination, even though a number of leading medical specialists were unconvinced of its value. Ultimately, administrative considerations, not scientific ones, were to prove decisive. Recruitment to the nursing profession was suffering from the widespread view that contact with TB patients was risky. Vaccination had the potential to provide reassurance to potential recruits and avert the threatened shortage. Objections regarding efficacy were also becoming muted. In 1949 BCG vaccination began to be offered to nurses. By 1956 positive results were emerging from a Medical Research Council (MRC) trial amongst fifty-six thousand schoolchildren. However, mass vaccination of children was already under way. Greater commitment to vaccination as a component of preventative healthcare fit well with the British government’s plans for its new National Health Service (NHS). Matters were far more urgent in countries that had suffered under German occupation. Travelling around Poland in 1946, a Danish relief mission found TB to be rampant and local facilities to deal with the disease wholly inadequate. Neither mass radiography nor the recently developed antibiotic streptomycin was available on the scale needed. The BCG vaccine seemed the only feasible approach, and in early 1947 a Danish Red Cross team began vaccinating Polish children. In the first six months of the campaign, forty-six thousand children were vaccinated. Support for extending vaccination further soon came from the United Nations Children’s Emergency Fund (UNICEF), created in 1946 to provide food, clothing, and

Politics of Global Vaccination Policies   587 healthcare to children in a number of devastated European countries (Brimnes 2008; Comstock 1994). By early 1948 Norwegian and Swedish relief organisations agreed to work with the Danes, establishing what became known as the Joint Enterprise. UNICEF agreed to support the Joint Enterprise with US$2 million for its work in Europe and to provide a further US$2 million for vaccination activities in Asia, Africa, and Latin America. On July 1, 1948, the Joint Enterprise, later renamed the International Tuberculosis Campaign (ITC), officially took over the activities started by the Danish Red Cross. One of the first acts of the newly established World Health Organization (WHO) was to set up the Committee on Biological Standardisation. This committee would have to ensure that BCG vaccine produced by laboratories in Europe, India, and Mexico was of a standard quality and strength. The ITC was scheduled to function until June 30, 1951, after which the campaign would be integrated into WHO’s work programme as a priority activity. An institutional division of labour was agreed upon whereby UNICEF would be responsible for BCG vaccine supplies and individual governments for managing the programme within their territories. In 1948 the government of newly independent India announced that it would start its own trial BCG vaccination programme and turned to the ITC for assistance. The Bhore Committee, which had produced a blueprint for the country’s future health services in 1946, though generally opposed to disease-specific programmes, was nevertheless in favour of mass vaccination (Brimnes 2007). For its supporters, vaccination exemplified the government’s commitment to modernisation and technological progress. But there was also political resistance to vaccination in India. Some critics saw it as a means of avoiding the structural causes of infectious disease. Others argued that vaccination was a ‘colonial’ and ‘un-Indian’ practise (Brimnes 2007). The programme nevertheless went ahead, and when ITC physicians left in 1951, the Indian authorities took over responsibility for BCG vaccination. Whilst vaccination had to be an element in international TB control, some at WHO questioned how far vaccination should be relied upon. Whilst WHO had little money and no means of developing and implementing any alternative strategy, evidence for the efficacy of BCG vaccination remained inconclusive. Prior studies, confirmed by reanalysis of data, pointed to vast variations from one place to another in the effects of mass vaccination on the incidence of tuberculosis. Some studies found a protective effect of around 80 percent, whilst others found none (Gheorghiu 1996). Despite these uncertainties, UNICEF and WHO were committed to mass BCG vaccination in what tended to be known then as the developing world. Vaccination was admittedly a ‘technological fix’, but it was feasible and relatively cheap. Tackling the structural causes of TB, rooted in widespread poverty and social disadvantage, seemed impossible. But to convince those who still questioned the vaccine, better evidence for its efficacy was needed. In 1968 the largest ever trial of BCG vaccination began, in Chingleput District (near to what is now Chennai, then Madras), India. It was conducted by the Indian Council of Medical Research, supported by WHO and the US Public Health Service. The methodology of the trial was carefully reviewed by independent experts, and in 1977 the results

588   Stuart Blume began to emerge. To the consternation of the Indian medical authorities and WHO, the findings showed no protective effect whatsoever. Yet WHO and the public heath establishment were not willing to abandon the vaccine (Eickhoff 1988). A variety of reasons (e.g., genetic variability of populations, the trial having been conducted on adults only) were put forward for not placing too much weight on the study results. The most important reason, however, was that there was simply nothing else affordable that could be done to tackle the disease.

Vaccine Cooperation Amid Cold War Rivalries Following the end of World War II, as the industrialised world became increasingly polarised, Eastern and Western bloc countries had different visions of how public health systems should be established and organised, both domestically and in parts of the developing world where they competed for influence. Notably, political leaders on both sides of the ideological divide felt that noteworthy success in controlling the spread of infectious diseases would reflect well on their respective political systems. Vaccine researchers had little difficulty in cooperating across the ideological divide to develop new vaccines against diseases such as poliomyelitis. In contrast, as vaccines were turned into symbols of ideological rivalry, their application became loaded with political significance (Litsios 2002; Vargha 2014). In divided post-war Germany, this Cold War rivalry played out particularly visibly. The Federal Republic of Germany (FRG), and specifically the western-controlled section of Berlin (which had special administrative status), developed vaccine policies with one eye on what the East Germans were doing (Lindner and Blume 2006). In April 1960 the German Democratic Republic (GDR) began vaccination using Albert Sabin’s oral polio vaccine (OPV). Within a year almost the entire population had been vaccinated. The FRG, where responsibility was vested in the individual Länder, had started using Jonas Salk’s rival inactivated polio vaccine (IPV), but only succeeded in vaccinating a small proportion of its population. These successes and failures were portrayed as a reflection on the different political systems within which they were undertaken. The FRG’s failure concerned far more than disease prevention. Ideological competition between the two German states proved a key factor that eventually goaded West German authorities into action. Another was international pressure. At international polio conferences, the FRG’s poor record soon became a matter of growing political embarrassment. Having started IPV vaccination with little enthusiasm, just a few years later West German Länder jostled amongst themselves to be the fastest, and the most efficient, in introducing free OPV vaccination. The programme was an immediate success, with twenty-three million people vaccinated in 1962.

Politics of Global Vaccination Policies   589

The High Politics of Malaria and Smallpox Eradication Having left WHO soon after its founding in 1949 on the grounds that the UN specialised agency was too heavily influenced by the United States, the Soviet Union and its allies rejoined in 1957 (Siddiqi 1995). Immediately thereafter Eastern bloc countries began to urge reconsideration of WHO priorities. The Soviet delegation to the 1958 World Health Assembly (WHA) proposed that WHO commit itself to a smallpox eradication campaign. Despite the country’s poor health infrastructure, the Soviet Union had succeeded in stopping smallpox transmission years previously. However, the disease continued to be imported by travellers from abroad, which meant the costly vaccination programme needed to continue. Victor Zhadnov, a virologist and head of the Soviet delegation to WHO, argued that transmission could be halted if 80 percent of the population were vaccinated. If this could be accomplished on a global scale, costly vaccination could be ended everywhere. Although the WHA accepted Zhdanov’s proposal, WHO director general Marcolino Gomes Candau remained unenthusiastic. The organisation was already heavily committed to malaria eradication, backed by strong political and financial support from the US government. Candau not only doubted the technical feasibility of smallpox eradication, he was reluctant to see scarce resources diverted from the malaria effort. Thus, although smallpox eradication was officially accepted as a WHO priority in 1958, virtually no resources were devoted to it. Consequently, each year thereafter the Soviet delegation complained about the lack of progress (Siddiqi 1995). By the early 1960s, however, there were indications that the malaria eradication campaign was failing, especially in Africa. This was concerning to the US government, which was embroiled in the Vietnam War. The malaria campaign was a humanitarian enterprise with which to shore up its reputation amongst non-aligned countries in the developing world. However, as evidence for the campaign’s failure accumulated—a result of growing microbial resistance, lack of resources, and tactical problems—it became clear that malaria eradication no longer fit the bill (Packard 2007). At the 1965 WHA, the US delegation switched its attention to smallpox. Now allying itself with the Soviet Union, the US delegation argued for a concerted attack on the disease. The WHO director general was requested to draw up a specific plan, to be presented at the next WHA, for an eradication campaign. After a heated debate on the additional costs involved, at the 1966 WHA the plan was accepted. High-level political backing, even from both superpowers, was no guarantee of success, however. Despite progress, the smallpox eradication programme soon faced major obstacles in the form of regional conflicts and powerful nationalist sentiments, notably on the Indian subcontinent (Brimnes 2017). In 1971, as Bangladesh gained in­de­pend­ ence from Pakistan, hundreds of thousands died, and many more, perhaps millions, fled

590   Stuart Blume to neighbouring India. Regionalism, heightened nationalist sentiments, and ethnic and religious divisions all meant that the WHO-led programme did not have an easy passage in a region critical to achieving smallpox eradication. In 1973 the Indian subcontinent was singled out by the campaign for concentrated international attention, in the light of the ongoing challenges and the many difficulties faced by the Indian government’s own eradication programme (Bhattacharya 2004). Large numbers of foreign (mainly American) physician-epidemiologists were flown into the region to support the national programme. The new ‘ring fence’ strategy introduced meant that everyone in a village in which a case of smallpox had been identified was to be vaccinated, irrespective of prior immune status and even consent. People who resisted were reportedly vaccinated using force, a reflection of the high-level political importance given to the eradication effort (Greenough 1995). In contrast to the Cold War rhetoric with which the United States and the Soviet Union positioned themselves in other realms of international relations, the two superpowers collaborated closely on smallpox eradication. Though their reasons might have differed, each saw eradication as in its interests. Moreover, key medical and scientific experts felt little political difference and had no difficulty working together. There was a division of labour, with the United States supplying most of the money and skilled personnel and the Soviet Union most of the vaccine. Following the failings of malaria eradication, the 1980 declaration that smallpox had been eradicated from the globe boosted political support for mass vaccination campaigns.

The Expanded Programme on Immunisation: Discursive Compromise and National Autonomy As the campaign for smallpox eradication progressed triumphantly, experts in international health began to wonder if it could provide a model for other vaccination programmes. Infectious diseases were by far the most important public health problem in tropical countries, and it was thought that if children were mass vaccinated, the accrued health gains would be substantial (Bulatao 1993). Of the eighty million children born annually in the African, Latin American, and Southeast Asian regions, only around four million were being effectively immunised during the 1970s. Furthermore, experience in the Northern Hemisphere showed that smallpox, diphtheria, pertussis, tetanus, poliomyelitis, and measles, and to some extent tuberculosis and typhoid fever, could be brought under control through vaccines. Thus, in late 1973 WHO set up an internal working group that fleshed out the idea of an expanded programme. In May 1974, as the smallpox campaign was entering its final stages, the WHA adopted Resolution 27.57, establishing what became known as the Expanded Programme on Immunisation (EPI). The resolution recommended that WHO member states “develop

Politics of Global Vaccination Policies   591 or maintain immunisation and surveillance programmes against some or all of the following diseases: diphtheria, pertussis, tetanus, measles, poliomyelitis, tuberculosis, smallpox and others, where applicable, according to the epidemiological situation in their respective countries” (WHO 1974). The resolution also requested that the WHO director general ‘intensify at all levels of the Organisation its activities pertaining to the development of immunisation programmes, especially for the developing countries; to assist Member States (i) in developing suitable programmes by providing technical advice on the use of vaccines and (ii) in assuring the availability of good-quality vaccines at reasonable cost; to study the possibilities of providing from international sources and agencies an increased supply of vaccines, equipment and transport and developing local competence to produce vaccines at the national level’ (WHO 1974). From the perspective of WHO, in other words, national governments themselves were recognised as needing to take the lead in initiating vaccination programmes. WHO representatives stressed that no one would be forced to introduce any particular antigen, and that action would only be triggered by a request for assistance. A member state could approach WHO for help in determining whether, and if so how, it could adapt the arrangements put in place for smallpox eradication to boost vaccination against other diseases. Over the course of the following months, the WHO Secretariat set about mustering financial support for the nascent vaccination programme. The Danish, Dutch, and Swedish governments soon responded positively. By early 1975 the participation of UNICEF was also agreed upon at the UNICEF-WHO Joint Committee on Health Policy. A series of regional seminars was organised, designed to explain to national policymakers what an expanded immunisation programme (beyond the existing smallpox and tuberculosis programmes) would entail. WHO offered national authorities help with planning, whilst UNICEF assisted with vaccine procurement. The United Nations Development Progamme (UNDP) indicated it would be willing to fund some trial implementation programmes. Because infectious diseases are known to interact with other health conditions, such as childhood malnutrition, there are good reasons for integrating immunisation programmes with other maternal and child health services. That this was frequently emphasised in WHO pronouncements also reflected the tensions in international health at the time. WHO and its representatives found themselves needing to tread carefully in formulating recommendations or even discussing the EPI. By the mid- to late 1970s, the Health for All movement had gained political momentum, culminating in the adoption of the Declaration of Alma Ata on Primary Health Care. The central ideas of this movement, an extension of the new international economic order, was a call to support health development as a socioeconomic issue and a human right, with equity and a strong role for the state at its core. The major commitment to extending and expanding vaccination programmes, which WHO was now making, had the potential to imply alignment with the so-called vertical approach to targeting specific diseases, by the early 1980s increasingly favoured by some parts of the international health community, including UNICEF and the US government (Mills 1983). Not only did the Soviet Union argue for a horizontal

592   Stuart Blume approach (prioritising primary healthcare rather than disease-specific interventions), but so did Halfdan Mahler, who became WHO director general in 1973. WHO staff sought to resolve this dilemma by emphasising that countries should make every effort to integrate immunisation programmes into primary healthcare as far as possible. Immunisation programmes, it was argued, should be seen as a foundation upon which a system of primary healthcare could be built (Henderson 1989). As more and more countries established immunisation programmes or increased the scope of existing programmes, the numbers of children vaccinated rose rapidly. There seemed to be reason for optimism, and in 1977 a more ambitious goal was established for the EPI. The international community committed to ensuring that every child in the world would receive the standard EPI vaccines (against diphtheria, pertussis, tetanus, poliomyelitis, measles, and tuberculosis) by 1990. Slowly but surely, however, and despite the rhetorical emphasis on vaccination as a key component of primary healthcare, the two began to be decoupled both administratively and organisationally at the country level. The demonstration of progress towards global coverage targets, vital if donor funding was not to be lost, became the key priority, not to be compromised by the priorities or politics of individual countries. Relatively simple quantifiable measures, such as percentage of targets met, were given greater importance than more complex, less easily quantifiable goals that underpinned the horizontal approach. For public health officials who still believed in primary healthcare, a high level of immunisation coverage was not in itself an appropriate measure of progress in healthcare (Newell 1988). It soon became clear that considerable extra resources would be needed for there to be any chance of vaccinating every child in the world by 1990. In 1984 several of the major international organisations concerned with health met to discuss the implications. At this meeting, the World Bank, UNDP, and Rockefeller Foundation joined WHO and UNICEF in establishing the Task Force for Child Survival. The task force was to serve as a catalyst, mobilising support for immunisation (and other healthcare initiatives) amongst donors. The recently retired director of the US Centers for Disease Control and Prevention (CDC), William Foege, was invited to head this task force. As discussed later in the chapter, this task force would play a major role in establishing polio eradication as a goal of international (and later global) health.

Economic Globalisation and Disease Eradication During the 1980s, in the early years of EPI, support for local vaccine production and the establishment of local and regional vaccine markets were accepted as important policy objectives. A decade or so later, in a very different ideological climate, discourse had shifted, and these objectives were quietly abandoned. The new neo-liberal climate emphasised privatisation, the freer play of market forces, a reduced role for the state, and additional

Politics of Global Vaccination Policies   593 patent protections for (corporate) inventors. The World Bank made its loans (which were becoming increasingly important in the health sector) conditional on privatisation, decentralisation, and fee-for-service payments, and there is now extensive evidence of their devastating effects on the accessibility of healthcare in much of the developing world (Homedes and Ugalde 2005). Countries were obliged to dismantle what were described as protectionist barriers to the freer flow of capital and goods and to rewrite legislation that restricted the patenting of medicines (Tyfield 2008; Waitzkin et al. 2005). During this period Australia and Sweden ceased producing vaccines in the public sector, a practise dating to the beginning of the century. Influenced by both economic arguments (‘it isn’t cost-effective to produce for a small national market’) and ideological considerations (‘this is not something a government should be doing’), other governments (including the Netherlands and Denmark) followed suit. The legitimacy and cost-effectiveness of production in the public sector were called into question (Milstien et al. 1997). As public facilities were sold off to private industry, the link between national health priorities and vaccine supply became attenuated. Moreover, the commercial sector was also changing amid economic globalisation. Much of the basic research that could lead to a new generation of genetically engineered vaccines had been carried out by small biotechnology firms. Since this research was their principal resource and hope of profitability, they patented it vigorously (Huzair and Sturdy 2017). Vaccine production was increasingly dominated by a small number of large pharmaceutical companies, vacuuming up all the ‘intellectual capital’ they could and competing for, and in, markets that were becoming global in scale. International health policy, seen as the outcome of agreement amongst nations, was giving way to global health policy, to be formulated at a supranational level, in which industry would necessarily participate (Brown, Cueto, and Fee, 2006). Policymakers had to acknowledge companies’ interest in extending markets and recouping large-scale investments in vaccine research and development (R&D). However, concerns began to be raised that industry priorities could diverge from public interest needs. This was reflected in the dearth of interest in developing a malaria vaccine, for example, because adequate returns on investment seemed doubtful. Noting these shifts in the late 1980s, two knowledgeable insiders wrote that “[p]ublic health objectives and advocacy . . . do not drive business decisions, and vaccine development often stalls when commercial firms calculate the relative advantage of investing in vaccines versus other products. Ultimately, industry executives, not public health officials, make the decisions about which products to develop” (Freeman and Robbins 1991). In response to these trends, new mechanisms and inducements were designed that aimed to help reconcile corporate and public health interests. These included public-private partnerships, as well as financial inducements such as the use of advance market commitments (Plahte 2012) and the International Finance Facility for Immunisation. Designed to bring industrial resources and expertise to bear on public health objectives, in practise these innovations gave industry further influence over the formulation of those objectives. This is illustrated by the Children’s Vaccine Initiative (CVI), established in 1990, which pioneered the public-private partnership model in the vaccine field (Muraskin 1998). Linked with but separate from WHO, the CVI was to stimulate the development

594   Stuart Blume of new and more effective vaccines, ultimately leading to a universal vaccine containing all the antigens children require. Over the following ten years, unbridgeable disagreements emerged between the CVI’s European and American donors. The Europeans felt that the organisation was overly committed to technological solutions to address public health problems. Despite shifting its focus from development of new vaccines to supporting vaccine introduction, the CVI was closed down in 1999. Out of its ashes emerged, phoenix-like, a new institution with far greater resources (Muraskin 2005). The Global Alliance for Vaccines and Immunisation (GAVI), now known as the GAVI Alliance, was announced at the World Economic Forum in 2000. Amongst its principal sponsors, in addition to donor governments, were a number of nonstate actors, including the Bill and Melinda Gates Foundation and the International Federation of Pharmaceutical Manufacturers Associations (IFPMA). With a twenty-eight-member governing board that includes representatives of low- and middle-income as well as donor countries, industry, and civil society, the GAVI Alliance assumed a key role in articulating and implementing global vaccine policy. Its policy emphasises accelerated introduction of new vaccines, and the organisation subsidises their introduction in low-income countries (defined according to World Bank criteria). Alongside the shift towards economic considerations as an increasingly important determinant of vaccination policies was a return to the view that campaigns should aim not merely at controlling diseases, but at eradicating them. Though the roots supporting eradication are deeper, justification was clearly drawn from the officially announced successful global eradication of smallpox. At the time, WHO director general Mahler warned the world that “important lessons can be learned from smallpox eradication— but the idea that we should single out other diseases for worldwide eradication is not amongst them. That idea is tempting but illusory” (Birn 2011). His concern was that targeting eradication would further divert attention and resources from the structural and economic roots of ill-health and from the commitment to strengthening primary healthcare, which he saw as fundamental. Despite Mahler’s cautionary words, within a few months of smallpox eradication, moves to establish a follow-up eradication programme were under way (Muraskin 2012). A meeting was organised at the US National Institutes of Health (NIH). Though two of the principal architects of smallpox eradication, Frank Fenner and D. A. Henderson, argued that there were no feasible eradication targets, the organisers of the meeting were undeterred. The smallpox campaign had to be followed up, in their view; it mattered less what the target of a subsequent campaign would be. Measles and polio were put forward as the most likely candidates. There was a growing feeling in the CDC that measles eradication was feasible now that a more heat-stable vaccine had been developed and also desirable given that measles caused 900,000 deaths annually. Others, including Fenner and Henderson, questioned whether eradication, rather than disease control, should be a goal of global policy. Meanwhile the preference of the CDC eradicationists was swinging towards polio rather than measles. At a symposium on polio control held in Washington, DC, in 1983, almost no participants spoke in favour of a polio eradication campaign. Polio was not a major public health concern in the developing world, and control was deemed a more appropriate goal.

Politics of Global Vaccination Policies   595 Despite this lack of support, in 1985 the WHO regional office, the Pan American Health Organisation (PAHO), was persuaded by Ciro de Quadros, a charismatic epidemiologist from Brazil, to commit to polio eradication in the region by 1990 (Muraskin 2012). De Quadros believed that the commitment, resources, and infrastructure generated by such a commitment would lead to a strengthening of immunisation programmes in the region more generally. Some experts, including notably D. A. Henderson, though sceptical about the feasibility of global eradication, began to accept that eradication in the Americas could be achieved. It was argued that such an achievement would have the great benefit of attracting political support for improved control of infectious disease. Proponents of a polio eradication initiative set about gathering allies. In 1988 the Task Force for Child Survival organised a high-level meeting in Talloires, France, to establish health priorities for the 1990s. Foege and UNICEF executive director James Grant clearly stated their support for eradication. In the Declaration of Talloires issued by the meeting, polio eradication headed the list. Just two months later, and despite Mahler’s earlier warning, in 1988 the WHA passed a resolution committing the organisation to ‘the Eradication of Polio by the year 2000’ (WHO 1988). Over the next decade or so, despite considerable investment and a dramatic reduction in polio cases reported, the goal of eradication proved elusive. In 2005, by which time US$4 billion had been spent (twice the initial estimate), there were still nearly two thousand cases annually. In Afghanistan, India, Nigeria, and Pakistan, polio remained endemic due to the lack of access to all populations amid political instability and insecurity. Furthermore, the disease continued to be transmitted to other countries by international travellers. As the target date for eradication was repeatedly pushed back, a number of experts argued that the whole campaign had been a mistake from the start. In 2006 an article was published in the journal Science under the headline, ‘Is Polio Eradication Realistic?’ (Arita, Nakane, and Fenner 2006). The authors, prominent public health experts from Japan and Australia, explained why polio eradication was proving far more difficult than smallpox eradication. The smallpox campaign had taken ten years, whereas by 2006 the polio campaign had already been running for eighteen years. To the question ‘Should WHO proceed with its current global eradication program, in view of all the difficulties and uncertainties?’ their answer, in 2006, was ‘No’. Instead, they supported the more realistic goal of disease control and integration of the polio programme into the Global Immunization, Vision, and Strategy announced by WHO in 2005. D. A. Henderson, who had directed the smallpox eradication programme, also publicly stated that polio eradication was simply not feasible. Despite these high-profile and experienced opponents, continued setbacks, and costs rising far beyond forecasts, the leaders of the eradication campaign remain, to the present day, undeterred. At the time of writing, the new target date for polio eradication is 2019. If this is achieved, defined as no new cases of wild polio during that and succeeding years, the campaign will have taken thirty years—three times as long as smallpox eradication. Smallpox eradication cost a total of US$100 million (at 1980 prices), or approximately US$315 million at 2017 prices. To date, US$10 billion has been spent on polio eradication, with estimates that more than US$15 billion will be spent by 2018. To justify continued

596   Stuart Blume donor support, the Global Polio Eradication Programme (GPEI) has developed an economic model to argue that eradication will generate long-term savings. Interestingly, like the smallpox eradication programme, polio eradication has faced its biggest challenges on the Indian subcontinent. A recent ethnographic study provides fascinating insight into the political problems faced, including the crucial question of ownership and responsibility (Closser 2010). Whose programme is the GPEI? In Pakistan, it is presented as a programme of the Ministry of Health, with WHO and UNICEF representatives as advisers. Yet the study shows that it is these external advisers who dominate strategy meetings. Though the campaign is based on a 1988 WHO resolution, it is not exactly a WHO programme, either. As the GPEI website explains, it is ‘a public-private partnership led by national governments and spearheaded by the World Health Organisation (WHO), Rotary International, the US Centers for Disease Control and Prevention (CDC), and the United Nations Children’s Fund (UNICEF)’. In this sense, it is difficult to say where ultimate responsibility lies or who can be held accountable in the event of problems arising. Regardless of the success or failure of polio eradication efforts, just as smallpox eradication inspired a few determined eradicationists to launch the polio eradication initiative, GPEI is being used to launch further initiatives. It is being argued that when eradication is achieved (failure is not contemplated), the campaign should continue, using a similar organisational model to target different diseases (Sniadack and Orenstein 2013). The targets being promoted, notably malaria and measles, have been on the global agenda before. The United States initiated malaria eradication in the early 1950s, before failure led the programme to be downgraded, and the focus switched to smallpox. CDC epidemiologists had been dreaming of eradicating measles since the early 1980s, and in 1996 a meeting to discuss this goal was organised. Participants were convinced that global measles eradication was feasible and that a global eradication campaign, with a target date between 2005 and 2010, would “build on the successes of the global Poliomyelitis Eradication Initiative” (CDC 1997). They also agreed that for the campaign to be successful, measles would have to be ‘rebranded’ for parents in the industrialised world, who would have to be convinced that the risk is more serious than many believe. This practise is likely to be one of the factors underlying growing parental scepticism regarding vaccination, the phenomenon that has been labelled ‘vaccine hesitancy’ (Blume 2017).

The Dynamics of Vaccination Policies Today A decade ago political economist Alice Amsden examined the impact of US policy on development and on institutions such as the World Bank that support it (Amsden 2007). She argued that the United States had forced a transformation in the policies and practises

Politics of Global Vaccination Policies   597 of developing countries. Whereas until the 1980s the American government had been saying ‘do it your way’ (encouraging countries to develop their own institutions, policies, and thinking), from the 1980s onwards it was saying ‘do it our way’. Low- and middleincome countries suffered from the 1980s onwards because they were under pressure to conform to a particular model of trade and economic development. This review of the global politics of vaccination suggests that something similar has occurred in public health. A shift can be observed over the same three decades in the relations between national and international institutions. When the EPI began, national governments were offered technical help and support for public health priorities emerging from domestic politics. Today, the GAVI Alliance offers funds to accelerate the introduction of selected new vaccines. In 2005 WHO and UNICEF (2005, 24) jointly announced a new global strategy that would have four elements: ‘The global strategy proposes to sustain immunisation to those who are currently reached, extend immunisation to those who are currently unreached and to age groups beyond infancy, introduce new vaccines and technologies and link immunisation to other health interventions as well as to the development of the overall health system. It places immunisation firmly within the context of sector-wide approaches to health, highlighting the way immunisation can both benefit from and contribute to health-system development and the alleviation of system-wide barriers.’ Few people today find anything strange in the notion of a ‘global immunisation strategy’ or the ‘Global Vaccines Action Plan’ that followed Bill Gates’s proposal at the 2010 World Economic Forum. Speeding up the development and introduction of new vaccines has become a cornerstone of global health policy. However, the sources of these vaccines are changing. Whilst major multinational manufacturers are perhaps less committed to developing new vaccines against infectious diseases than they were twenty years ago, vaccine manufacturers based in Brazil, Russia, India, and China are expanding their R&D and production and developing international markets (Plotkin et al. 2015; Kaddar et al. 2014). Amongst the various global institutions concerned with immunisation, the GAVI Alliance has become the most significant, both because of the coherence and coordination it has brought to the field and because of the funds at its disposal. Today, a large share of the resources that WHO can devote to immunisation comes from GAVI, whilst many donor governments have chosen to channel their immunisation-related aid through the alliance. A proposal to devote a share of GAVI’s resources to strengthening the health systems that are expected to deliver immunisation faced initial opposition on GAVI’s governing board (Storeng 2014). Though the alliance is now committed to strengthening health systems, 75 percent or more of its funding still goes to supporting new vaccine introduction in poor countries. As a country’s annual per capita income rises beyond the threshold (currently $1,580), the country ceases to be eligible for GAVI support. The implications of this transition for the sustainability of a national vaccination programme are now a matter of concern (Kallenberg et al. 2016). Vaccine manufacturers have an obvious interest in standardisation. Costs are greatly reduced if identical formulations are used in identical ways irrespective of country.

598   Stuart Blume However, vaccination schedules are a national responsibility, and differences remain, even amongst European countries. For example, about half of these have no compulsory vaccinations, whilst the others have one or more, most commonly polio. Both France and Italy extended mandatory vaccination at the beginning of 2018. In Italy the ruling was reversed six months later by the new populist coalition government. Irrespective of whether vaccination is mandatory or voluntary, vaccination rates in Western European countries are generally high. At the same time, the number of vaccines routinely offered to babies and infants is rising. A baby born today is likely to receive twice as many vaccines as its grandparents. How does this come about? On what basis do governments decide to introduce a new vaccine? In many countries a standing expert committee provides ministers of health with precisely this kind of advice. In the United States it is the Advisory Committee on Immunization Practices (ACIP), and in Britain it is the Joint Committee on Vaccination and Immunisation (JCVI). When a recommendation relating to a new vaccine is required, mortality and morbidity data relating to the disease in question are reviewed, and the cost-effectiveness of the new vaccine is estimated. In Britain a vaccine will be recommended only if its cost will be less than £3,000 per quality-adjusted life year (QALY) gained. Whilst policy decisions, including vaccine policies, are supposedly evidence based, this rationalisation of the policymaking process assumes that all necessary data are available, and that decisions are not influenced by lobbying by vested interests. However, studies of actual decision-making suggest that these assumptions are not always justified (Sandberg and Justice 2013). In many cases, national data are lacking, and practises elsewhere are followed instead, even though the epidemiology of a disease may well differ from one region or climate to another. For example, the measles vaccine is known to be safe and effective but only 80 percent protective after a single dose. The vaccine should be given when an infant’s maternal antibody levels are neither too high to interfere with the effects of the vaccine nor too low to offer protection. In low-income countries in tropical climates, the intensity of exposure to measles virus is higher. Maternal antibodies also decline more rapidly than in temperate countries, so that infants are at risk of acquiring measles at a younger age. There are thus good epidemiological reasons for following a measles vaccination schedule different from that employed in Northern Hemisphere countries. However, since the studies needed to establish the optimum schedule for immunisation are costly and time-consuming, many low-income countries are obliged to use evidence from elsewhere (Behague et al. 2009). In India, public health activists have criticised the evidence base for domestic vaccine decision-making (Madhavi et al. 2010). They argue that when replacement of a four-component by a fivecomponent vaccine was being considered, the government’s technical advisory body ignored evidence suggesting that this would yield little or no extra health benefit in India. A similar critique regarding the introduction of hepatitis B vaccine had been made previously (Madhavi 2003). In the latter case, the decision to introduce the vaccine was reportedly based on pressure from international organisations and the country’s thriving biotech industry, rather than on epidemiological evidence from India itself, which did not exist at the time.

Politics of Global Vaccination Policies   599 Indian activists have not been alone in questioning the way in which decisions to introduce new vaccines are made. In Guatemala, EPI staff were asked in mid-2009 to submit a funding request for the introduction of the rotavirus vaccine. Although rotavirus infection leads to serious (and potentially fatal) diarrhoeal disease, the local staff did not feel they could cope with the addition of a new vaccine, so they declined. However, a few months later the Guatemalan government informed them that the vaccine would be introduced. Public health experts, and the normal consultation process, appear to have been ignored (Burchett et al. 2012). This suggests that in low-income countries eligible for GAVI support, the availability of donor funding for rotavirus or hepatitis B, or some other new vaccine, can be sufficient to trigger the application of a vaccine regardless of national priorities. For governments in low-income countries, securing a share of GAVI funds may carry political weight regardless of actual health needs. There is a growing sense that vaccine policy today has little to do with the healthcare needs of local communities. Studies of local perceptions of the polio eradication campaign show this most strikingly (Closser 2010). Where doubts regarding one or more vaccines coalesce with widespread loss of trust in the state as such, passive vaccine hesitancy may grow, or active anti-vaccinationism may emerge (Obadare 2005; Pop 2016). Policymakers are now obliged to take these phenomena very seriously (Eskola et al. 2015). Unfortunately, as the connection with populist political movements suggests, restoration of faith in the benefits of vaccination will not be achieved with the traditional tools of public health alone (Blume 2017).

Conclusion Over the course of a century, vaccination has evolved from its once modest role in public health, tentatively applied by individual countries and for particular diseases, to become a cornerstone of global health policy. When mass vaccination against tuberculosis was in full swing in the 1950s, vaccination was acknowledged to be a technological fix: valuable until such time as the root causes of infectious disease mortality could be tackled. The success of the vaccine-based smallpox eradication programme further spurred expansion of vaccine use. It also evoked enthusiasm for further eradication programmes. Today, vaccine development and expanded applications for an ever-growing range of diseases have become a “go to” approach to tackling the global burden of infectious. For the public health community, seeking to demonstrate effective action, vaccine deployment offers the benefit of measurability. Targets can be specified and progress towards them quantified. Simple but powerful numbers—percentage coverage, number of lives saved—appeal to donors and the public, who in turn facilitate the mobilisation of resources. Global health discourse, as a result, has become replete with vaccination coverage statistics (Greenwood 2014). Poor coverage, or failure to take advantage of a new vaccine (when neighbouring countries have done just that), can be embarrassing. One consequence, as previously noted, is that GAVI-eligible countries may introduce a

600   Stuart Blume vaccine for which funding is available just to secure a share of funding and appease ­donors rather than to meet local needs. As well as diverting global and local resources, there is uncertainty about the sustainability of such policy decisions, as countries will eventually have to assume responsibility for vaccine costs. High-income countries have the capacity to resist such pressures and can pursue a more independent line on the adoption of vaccines (e.g., some have chosen not to introduce chickenpox vaccine, or to limit hepatitis B vaccination to risk groups, or to limit HPV vaccination to girls only). Pressures to harmonise vaccination schedules and to introduce new vaccines remain, however. The contemporary dynamics of global immunisation policy is undoubtedly driven, in part, by the profitability of vaccines to an increasingly globalised pharmaceutical industry. According to Kaddar (2012), the global vaccines market not only tripled in value between 2000 and 2013 (from US$5 billion to almost US$24 billion), but is projected to rise to US$100 billion by 2025, with more than 120 new products in the development pipeline. Whereas forty years ago vaccines were of only marginal interest to the pharmaceutical industry, today they are one of the (or perhaps the) principal sources of revenue growth. At the same time, how vaccines have come to occupy this central position must also be understood as shaped by different perspectives in global health policy, notably between those who favour technically driven, disease-focused approaches and those who seek to strengthen health systems, support primary healthcare, and address the broad determinants of health. This is a long-standing divide, sustained by ideological differences, regarding the appropriate roles of the state and market, the importance of health equity, and the meaning and measurement of health development.

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chapter 31

The Gl oba l Politics of Acce ss to M edici n es From 1.0 to 2.0 Suerie Moon and Ellen ‘t Hoen

Access to medicines has been both a central goal and a fierce battleground in global health. This chapter begins by explaining the key issues and why the politics has been so contentious. It then provides a history of the considerable evolution in how ‘access to medicines’ hvas been framed and understood as an issue since the 1970s and an analysis of the resulting political implications. We continue with an account of ‘access to medicines 1.0,’ which centred largely on access to HIV medicines and intellectual property (IP) rules, then offer an explanation of the significant ideational and political shifts that have resulted in what may be termed ‘innovation and access 2.0.’ The chapter concludes with an analysis of what this shift implies for the global politics of medicine policies and for global health more broadly.

Background Access to medicines has been one of the most politically polarised issues in global health. In 2010 Dr Margaret Chan, then director-general of the World Health Organization, remarked at an annual meeting of WHO, the World Trade Organization (WTO), and the World Intellectual Property Organization (WIPO): ‘Of all the issues discussed at WHO governing bodies, access to medicines consistently sparks the most heated, sometimes divisive, and potentially explosive debates’ (Chan 2010). It has given rise to street protests; been the subject of intense lobbying by corporations, governments, and non-governmental organisations (NGOs); and frequently pitted governments of the global North against the global South in intergovernmental arenas.

606   Suerie Moon and Ellen ‘t Hoen What does the phrase ‘access to medicines’ refer to in the context of global health politics? Many determinants shape the long chain of events between the development of a medicine and its use by a patient, including prescriber and patient behaviour, supply chains, broader health systems, tax and importation policies, regulatory and quality assurance processes, and manufacturing. However, these are generally not the issues that have sparked such ‘explosive debates’. Rather, it is the political conflict over the price of medicines, and in particular the role of IP rights in enabling high prices, that has been so polarising. This debate has at its core differing views of the appropriate roles and responsibilities of states versus markets and of the appropriate balance between the right to health and economic interests. Perhaps it should be no surprise that the politics is fierce. It is not an exaggeration to say that access to medicines can make the difference between health and illness, life and death. (In this chapter, for the sake of brevity, we use the general terms ‘medicines’ and ‘health technologies’ interchangeably to refer broadly to drugs, vaccines and other biologics, diagnostics, and medical devices.) At the same time, billions of dollars and the interests of powerful global industries and governments are at stake.

Why Does Access to Medicines Matter to People and Health Systems? Medicines are a necessary component of fulfilling the right to health. They can alleviate suffering. They can prevent, diagnose, and treat disease, thereby saving lives. They can control and stop outbreaks of infectious disease. They can provide security to a population and reduce panic, stigma, and fear related to disease. They are a necessary input for any health system to function and on average comprise 20–30 percent of a society’s total health expenditure. In general, the poorer the country, the larger the share of total health spending dedicated to medicines; in some of the poorest countries, medicines account for 30–60 percent of health spending. Therefore, medicine prices are of particular concern to developing countries, where on average higher disease burden, combined with lower capacity to pay and higher reliance on medicines, make the cost a critical social issue. Furthermore, unlike other health services that are often covered by public or private insurance, medicines are frequently financed by out-of-pocket spending, making prices a particularly regressive financial burden on individuals and households (Lu et al. 2011). Medicine use has been steadily increasing over the past decade and is projected to continue doing so. Economic growth in middle-income countries (MICs), ageing populations worldwide, and the growing burden of chronic diseases that often require longterm medicine use all suggest that access to medicines will continue to be a major societal challenge and pressing political issue in the decades to come.

Global Politics of Access to Medicines   607 Healthcare in general and medicines in particular are also big business. The health sector, estimated at about US$9 trillion per year, accounts for 1/10th of the global economy.1 Pharmaceuticals (drugs, vaccines, and other biologics) were a US$1,135 billion market in 2017, comprising 1 out of every 8 dollars of healthcare spending. Spending on medicine grew at an annual pace of 6.2 percent for the period between 2013 and 2017, outpacing inflation and other healthcare spending in many countries. About half of medicine spending is on new drugs (i.e., patented, ‘branded’, ‘originator’), with the remainder of the market accounted for by generics (Quintiles IMS 2017). Global investment in research and development (R&D) in health technologies is estimated at US$240 billion per year, of which about 60 percent comes from the private sector and 40 percent from the public and non-profit sectors (Røttingen et al. 2013). Two-thirds of the global market remains in just ten high-income countries, but twenty emerging economies have been identified as ‘pharmerging’ markets in which volume and revenue growth has outpaced the rest of the world (Quintiles IMS 2017).

How Have Concerns about Access to Medicines Shaped Global Health? Access to medicines was central to the rise in development assistance for health that characterised the first fifteen years of the twenty-first century, and will continue to be central to the global political conflicts that will shape global health in the decades to come. Improving access to medicines was the driving rationale for the largest global health initiatives that were launched after the turn of the millennium. For example, increasing access to medicines was a specific target in both the Millennium Development Goals and sustainable development goals, as well as a necessary component of numerous other targets and broader health goals. The GAVI Alliance (formerly the Global Alliance for Vaccines and Immunization) was created in 2000 to expand access to newer vaccines and improve immunisation rates in the poorest countries; about two-thirds of its annual spending of roughly US$1.5 billion goes towards vaccines and programme implementation (GAVI, The Vaccine Alliance 2017). The Global Fund to Fight HIV/AIDs, Tuberculosis and Malaria was created in 2002 primarily as a vehicle to channel large-scale international financing of antiretroviral (ARV) treatment for HIV/AIDS to developing countries. One study calculated that 44 percent of its expenditure was on commodities such as drugs, bed nets, and diagnostics (Duran and Silverman 2013). UNITAID was founded in 2006 with an annual budget of about US$300 million and a core mission to make global medicine markets work better for global health. Finally, about two dozen public-private product development partnerships (PDPs) were created between the late 1990s and early 2000s to develop affordable new medicines for a range of neglected diseases (Ziemba 2005). From 2007 to 2016 an average of about US$521 million per year was

608   Suerie Moon and Ellen ‘t Hoen invested in R&D through PDPs (Policy Cures Research 2017). Whilst many other global health initiatives were also launched in this period, the emphasis on access to medicines in the largest ones underscores how central this issue has been in global health. In addition, medicine issues have been amongst the most contentious, as noted previously. Debates over IP rules and medicine prices have deeply divided North from South. They have also created unprecedented linkages between policy processes in the global health and trade arenas and raised awareness of how global governance processes outside the health sector could profoundly impact health. Finally, they have illustrated how private for-profit and non-profit actors can deeply influence global health governance processes, which remains a central concern for scholars and policymakers alike. We return to some of these themes in the conclusions section of this chapter, but first look back at the history of how medicine issues came onto the global agenda.

History How and when did access to medicines emerge as a subject of global health politics? In this section we trace the considerable evolution in how medicine issues were framed from the 1970s to 2000—concerns regarding access largely developed along one track, whilst those focusing on innovation evolved on another (in subsequent sections we discuss how these two issues later came to be seen as inseparable).

History of Concerns Regarding Medicine Access Medicine policy debates began to ‘globalise’ in the 1970s when WHO began working on its first ‘Essential Drugs List’, published in 1977 and containing 207 items ‘that satisfy the priority health care needs of the population’ (Wirtz et al.  2017). At the time, policy debates and objectives did not focus centrally on ‘access,’ as they later would; rather, a range of concerns relating to pharmaceutical policy in developing countries was on the agenda, from marketing of dangerous medicines to appropriate use, and from quality of production to affordable prices. The essential drugs concept was pioneered as part of the drive for primary healthcare. In 1978 the Alma Ata Conference outlined an agenda to achieve ‘health for all by the year 2000’ in which the selection and supply of essential medicines was identified as a core function of the government (‘Declaration of AlmaAta’ 1978). Dr Halfdan T. Mahler was the visionary director-general of WHO at that time and a driving force behind the concepts of primary healthcare and essential drugs. In 1982 he established a dedicated WHO programme to encourage the availability and correct use of essential medicines called the WHO Action Programme on Essential Drugs, which became known as the Drug Action Programme. One of the earliest NGOs to work on pharmaceutical policy issues at the international level was Health Action International (HAI), founded in 1981 in response to the rallying

Global Politics of Access to Medicines   609 cry of ‘health for all NOW,’ signalling impatience with the 2000 deadline for progress. Members of HAI and consumer and health advocates from around the world worked to call attention to double standards in the pharmaceutical industry, which sold dangerous, ineffective medicines in developing countries even when these products were banned in their home countries (Chetley 1986). In 1982 HAI and the International Organization of Consumer Unions (IOCU) published a draft marketing code for pharmaceuticals. HAI presented the code at the UNCTAD Committee on the Transfer of Technology in the hope that United Nations (UN) agencies such as WHO would collaborate to develop a UN International Code on the marketing and rational use of pharmaceuticals. The proposal was met with fierce opposition by the industry and wealthy nations. But the campaigning work by HAI working with the IOCU had raised the profile of pharmaceutical issues internationally. In 1985 WHO director-general Dr Mahler organised a historic conference in Nairobi to develop a new medicine policy for the organisation and invited several parties to the table, including HAI and industry representatives. The meeting discussed a wide variety of themes, including how to select essential medicines; what measures to take to increase access to medicines; how to encourage the correct prescription by physicians and the proper use by consumers of medicines; how to establish government regulations to ensure that medicines are effective, safe, and of good quality; the lack of meaningful R&D; and how to regulate the drug industry and its drug-promotion practises. Local production of essential medicines in developing countries was also a theme of the meeting, not only as an industrial development objective but also as a way to decrease de­pend­ence on Western companies. At the opening of the Nairobi Conference, however, Mahler had made it clear that the topic of medicine patents would be excluded from the discussion because ‘it was felt that the main ways of making drug use more rational could be clarified without them’ (World Health Organization 1987). The conference laid the groundwork for the 1986 adoption of WHO’s new medicine policy, the Revised Drug Strategy (RDS). The RDS recommended a series of actions to ensure the availability of affordable essential medicines and strategies to improve the use of medicines (‘the rational use of drugs’). The RDS became WHO’s medicine policy for the following decades. It built strongly on the concept of ‘essential drugs,’ which were at the time available from multiple generic suppliers. Dr Ernst Lauridsen, the first director of the WHO Action Programme on Essential Drugs, described WHO’s new medicine policy as a ‘peaceful revolution in international public health’ (World Health Organization 1987). However, the adoption of this new policy did not happen without controversy. The pharmaceutical industry saw the concept of essential medicines and WHO’s work with governments on medicine policies as a frontal attack on its freedom to operate and feared that it would lead to government interference in the industry’s marketing practises. In 1977 the International Federation of Pharmaceutical Manufacturers & Associations (IFPMA), the main international lobbying organisation for the multinational pharmaceutical industry, called the medical and economic arguments for the Essential Medicines List ‘fallacious’ and claimed that adopting it would ‘result in substandard

610   Suerie Moon and Ellen ‘t Hoen rather than improved medical care and might well reduce health standards already attained’ (Drahos 2010). The industry was particularly concerned that the Essential Medicines List would become a global concept, applicable beyond the developing world, and, for example, would be used for priority setting in the marketing approval of medicines or in the reimbursement decisions of health insurance companies in industrialised countries (Hordijk 2017). Countries would indeed use the list to exclude drugs on the Essential Medicines List from patentability, as was the case in the Andean region; to remove medicines from the market; to establish price controls; and to develop their own national manufacturing capacities. Not by coincidence, whilst WHO was formulating the RDS, pharmaceutical companies were establishing an elite, high-powered lobbying group that worked to include IP in the General Agreements on Tariffs and Trade (GATT) framework, the predecessor of the WTO. These efforts succeeded over the opposition of several developing countries and led to the adoption of the WTO Agreement on Trade Related Aspects of Intellectual Property Rights (TRIPS) in 1995 (Sell 2003). The RDS strongly recommended that countries adopt a national policy encouraging the use of generic medicines, a recommendation that ran counter to the new obligations that countries took on under the WTO TRIPS rules in 1995. In the late 1990s, against the backdrop of the HIV/AIDS crisis and the struggle to access affordable HIV medicines, it had become apparent that the WHO medicine strategy risked becoming obsolete. Its advice was based on a world in which countries were at liberty to determine the kind of pharmaceutical patent regimes that they wished to have—a world that was quickly disappearing. WHO undertook to update the RDS to enable the organisation to advise countries in the implementation of the new global IP rules whilst assuring access to essential medicines (Velasquez and Boulet  1997). The discussions on adaptation of WHO’s RDS occurred at a point in history when IP became a controversial issue. Industry’s opposition to WHO’s involvement in IP issues was fierce (Velasquez and Boulet 2015). However, the topic was there to stay, and the obstacles posed by IP to access to medicines became a recurrent theme on the agendas of numerous multilateral agencies. We return to the issue of patents later in the chapter.

History of Concerns Regarding Innovation in Medicines In parallel to concerns about access to medicines, concerns about the ways in which new medicines were developed were also emerging—in particular, whose health conditions were (or were not) met, how well-adapted medicines were (or were not) for different parts of the world, and who could (or could not) ultimately benefit from advances in science and technology. The period from the 1970s to 2000 witnessed a significant shift in the global R&D system and norms regarding whom it should serve. Whereas modern pharmaceutical development was focused in a handful of industrialised countries after World War II, by the turn of the millennium a global innovation system had emerged populated

Global Politics of Access to Medicines   611 by global networks of scientific researchers and labs, multinational pharmaceutical companies, and extensive cross-border trade in raw materials and finished medicines. There were also major shifts in conceptions about who should benefit from and who should pay for medicine R&D, with gradual movement away from a primarily narrow national approach that focused on the needs of industrialised countries to an increasingly global approach that included the health conditions primarily affecting developing countries. This shift had important implications for political conflicts over medicines (Moon 2009). First, a brief overview of the medicine innovation system is merited. The R&D proc­ess for developing new medicines stretches across a long chain, often taking more than a decade, from basic scientific research to screening of potentially useful tools and compounds, to proof of concept, to clinical testing for safety and efficacy, to end-user access and post-marketing monitoring. The development of health technologies to combat disease has a long and storied history that reaches back thousands of years to the development of traditional medicines and continues forward through the germ theory of disease, to the emergence of a modern pharmaceutical industry, to today’s myriad products of advanced science and technology. Medicine development has long been a joint endeavour of the public and private sectors. On the public side, governments invest taxpayer money through national research agencies, the military, and/or academic institutions with the aim of generating benefits for the public. On the private side, firms invest in developing new products, expecting that profits made will provide a sufficient return on investment (Moon 2017). For many years innovation and access followed a trickle-down pattern: products were invented in the public or academic sectors and developed and brought to market by the private sector in industrialised countries; later, other organisations such as developing country governments, WHO, donors, and public health researchers picked up these inventions and adapted or applied them for use in developing countries. The medicines that emerged from this system were not specifically designed for use in developing countries, and they were not always well-adapted or affordable (Moon 2009). Beginning in the 1960s and 1970s, this situation began to change as attention to health in developing countries increased: in 1968 the US National Institutes for Health established the Fogarty International Center, in 1975 the UN Special Programme for Research and Training in Tropical Diseases (TDR) was founded, and in 1977 the Rockefeller Foundation launched the Great Neglected Diseases of Mankind international research network. These initiatives marshalled donor resources to build research capacity in, and fund research on, diseases primarily affecting developing countries. Compared to the earlier period, the type of innovation that occurred during this time was broader in scope, combining knowledge from both higher- and lower-income countries to develop new products for developing country health needs. However, whilst these new approaches to innovation yielded important advances such as new drugs for river blindness and insecticide-treated bed nets for malaria, overall they were not sufficient. At the close of the 1980s, for example, drug-resistant malaria was spreading across the globe, the AIDS epidemic had gained momentum, and there were no new tools to detect or treat tuberculosis; the innovation system had not kept up (Moon 2009).

612   Suerie Moon and Ellen ‘t Hoen The 1990s witnessed a growing appreciation for the importance of health research for development, coupled with increasing dissatisfaction with the existing institutions for innovation. The Commission on Health Research for Development’s (1990) report ‘Health Research-Essential Link to Equity in Development’ argued that research had long been ‘under-recognised and neglected’ as a tool for addressing growing global inequities in the health of populations and urged greater investment in health research at the national level in developing countries (Commission on Health Research for Development  1990). Not long afterward, the 1993 World Bank report ‘Investing in Health’ put health squarely back on the international development agenda, making the case that good health was critical to economic development (Musgrove 1993). Closely following on its heels was the 1996 report ‘Investing in Health Research and Development’, which focused more specifically on the questions of R&D (WHO Ad Hoc Committee on Health Research Relating to Future Intervention Options 1996). Finally, the 1999 publication of the Global Forum for Health Research, ‘10/90 Report on Health Research’(Currat et al. 1999), added an overtly normative dimension to the debates by arguing that spending only 10 percent of the world’s R&D dollars on health conditions primarily affecting 90 percent of the population was an unethical imbalance that should be corrected. The products of R&D were no longer framed purely as private goods but as potential public goods that ought to provide global benefits (Moon 2009). Actors subsequently began to experiment with new approaches to health R&D. For example, in 1996 the first ‘public-private product development partnership (PDP)’, the International AIDS Vaccine Initiative, was founded, bringing together governments, academia, industry, and civil society to accelerate progress towards a vaccine for HIV. About two dozen PDPs targeting various diseases were created in the decade that followed (Muñoz Tellez de Kieffer 2015). Throughout the 1980s and 1990s political debates about medicine access and innovation evolved considerably and largely took place along parallel tracks. The HIV/AIDS crisis and ensuing developments began to interweave these threads together and also thrust access issues into the limelight, as we discuss in the next section.

Access to Medicines Politics 1.0 HIV/AIDS played a central role in shifting the framing of ‘access to medicines’ away from the previous emphasis on securing access to the most basic ‘essential’ medicines towards a focus on making high-priced new medicines affordable and available in developing countries.

HIV and Patents At the turn of the millennium the global HIV/AIDS pandemic had reached an alarming scale and was increasingly recognised as a health, development, human rights, and

Global Politics of Access to Medicines   613 security crisis. At the time ARV therapy for HIV was reducing morbidity and extending life in the industrialised countries, translating a lethal diagnosis into a chronic one. However, at over US$10,000 per patient per year, the therapy was beyond the reach of most of the over thirty million people living with HIV, about 95 percent of whom lived in the developing world. At the same time, developing countries were just beginning to implement the TRIPS Agreement, which mandated a minimum level of patent protection and dismantled long-standing exceptions in national patent laws for medicines and food. As a result, developing countries were granting patent monopolies on AIDS drugs that blocked the use of generic medicines, even when they cost 98 percent less than the price of patented versions (Hein and Moon 2013). South Africa was one of the countries hardest hit by the HIV pandemic and became a critical battleground for global access to medicines politics. After the post-apartheid transition, the South African government had revised its medicine law in 1997 in an effort to make medicines more affordable to the majority of its population. Provisions of the Medicines Act included generic substitution of off-patent medicines, transparent pricing for all medicines, and the parallel importation of patented medicines. In February 1998 the South African Pharmaceutical Manufacturers Association and thirtynine multinational pharmaceutical companies brought suit against the government of South Africa, alleging that the Medicines Act violated TRIPS and the South African constitution (Barnard 2002). When the case came to court in 2001, it was widely covered in international media and prompted global public outrage over an industry that developed new medicines but denied access to them for the majority of people who needed them to stay alive (‘t Hoen et al. 2011). The reputational damage to the industry—and the disclosure that the most contentious section of the Medicines Act was based on a draft legal text produced by the WIPO Committee of Experts (Sidley 2001)—eventually drove the companies to withdrew the lawsuit in April 2001. The South African court case raised global public awareness of the lack of access to HIV treatment in the global South and the role of patent monopolies in sustaining high prices for HIV medicines; it also gave momentum to a growing global movement of HIV/AIDS, health, development, and human rights activists pushing for access to affordable HIV medicines. A critical linchpin in these debates was the issue of whether developing countries could use generic versions of medicines that were widely patented—in other words, whether public health concerns justified taking a more flexible approach to the interpretation and application of international and national IP laws. Doing so would require not only conducive legal conditions, but also political and economic ones. Legally, WTO rules allowed countries to lift the monopoly effect of patents using a measure called ‘compulsory licensing’, a standard provision also found in national patent laws. But the pharmaceutical companies and the governments of their home countries in the global North exerted strong political pressure on developing countries not to make use of such measures. In addition, there was the key practical question of where generic medicines could be manufactured and sourced. The Indian generic pharmaceutical industry played a central role in answering this question and was therefore critical in changing the course of HIV access debates. In early 2001 the Indian drug manufacturer Cipla offered ARV therapy at a cost of less than

614   Suerie Moon and Ellen ‘t Hoen a dollar a day, in contrast to the US$10,000 price tag then on offer from patent-holding companies (Zimmerman and Pesta 2001). Cipla’s price highlighted how cheaply medicines could be manufactured and also offered the hope that HIV treatment could be made affordable to governments and donors looking for ways to address the HIV crisis. Cipla’s offer was possible because the 1970 amendment of the Indian Patents Act excluded pharmaceutical product patents, allowing a vibrant generic industry to develop and providing the legal framework for large-scale generic production of ARVs (Chaudhuri 2005). The establishment of early AIDS treatment programmes in Brazil and Thailand in the late 1990s and early 2000s also played an important role in making low-cost global generic supply feasible. In both countries some HIV medicines were not patented and could be manufactured locally or imported as generics. The volume of demand from Brazil’s large-scale programmes, in particular, created economies of scale and reduced the price of the raw materials (active pharmaceutical ingredient) used for the production of ARVs on the global market, lowering the prices Indian companies were able to offer internationally (Fortunak and Antunes 2006). Importantly, Brazil’s and Thailand’s programmes also demonstrated that HIV treatment was feasible in resource-poor settings (Rosenberg 2001). Cipla’s groundbreaking 2001 price offer put more affordable generic medicines almost within reach, but countries still had to overcome patent barriers at the national level in order to access them. Global political debates continued at the WTO regarding what exactly was permissible under the TRIPS Agreement, but by mid-2001 negotiations between the group of African countries and industrialised countries had reached a stalemate. Later that year, when postal shipments of anthrax spores prompted a bioterrorism scare in the United States, an improbable path through the impasse opened up: health secretary Tommy Thompson was facing the possibility of shortages and high prices for ciprofloxacin, at the time the only drug known to be effective against anthrax. Thompson threatened the patent holder, Bayer, with a compulsory licence on the medicine (as did Canada). Whilst he never issued the licence, the episode changed the tenor of the debates around AIDS drugs. Two months later, at the WTO conference of trade ministers in Doha, Qatar, the United States found its opposition to the use of compulsory licencing untenable (Moon and Balasubramaniam 2018). In December 2001 WTO members issued a unanimous declaration stating that the TRIPS Agreement does not and should not prevent members from taking measures to protect public health. Accordingly, whilst reiterating our commitment to the TRIPS Agreement, 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)

The Doha Declaration strengthened and expanded the policy space available to governments to protect public health in the global IP regime. Other key provisions of the Doha Declaration included explicit assurance permitting parallel importation (trade in patented products when available at different prices in different countries), clarification

Global Politics of Access to Medicines   615 that members had the freedom to issue compulsory licences and to determine the grounds on which they could be granted, and extension of the transition period for LDCs to protect pharmaceutical patents until at least 2016 (later extended to 2033) (Abbott 2002). The Doha Declaration was a watershed moment that cleared the way for large-scale purchase of generic medicines by governments and donors. From 2001 onwards developing countries’ governments used the provisions of the Doha Declaration on a wider scale than perhaps is generally known. With reference to the Doha Declaration, countries started to import low-priced generic ARVS from India or allowed local production of ARVs. A 2016 study of 176 instances of the use of TRIPS flexibilities shows that between 2001 and 2016, 100 (56.8 percent) concerned compulsory licences, including public non-commercial use licences, and 40 (22.7 percent) concerned instances of the use of the LDC transition option to not enforce pharmaceutical patents. The vast majority of these instances (78 percent) concerned the procurement of medicines for the treatment of HIV (‘t Hoen et al. 2018). Amongst wealthy nations, donor governments committed to the establishment of the Global Fund, which opened its doors in 2003 and would become one of the world’s largest purchasers of generic HIV medicines. That same year the United States announced the President’s Emergency Plan for AIDS Relief (PEPFAR). France collaborated with Brazil, Chile, Norway, and the United Kingdom to establish UNITAID, a medicine financing mechanism based on the collection of a solidarity tax on airplane tickets that became operational in 2006. There was a growing realisation amongst the donors that for the money to stretch as far as possible and treat as many people as possible, wide access to low-cost, generic ARVs had to be guaranteed. The Doha Declaration was critical because it provided legal reassurance to suppliers of generic medicines in countries where the products were patent protected. In 2002 WHO added ARV medicines to the WHO Essential Medicines List. The decision to include highly priced HIV medicines on the EML ran counter to the decadeslong practise to only include medicines that were available as generics or at a low price. The WHO Prequalification Programme, established in 2003, provided the necessary regulatory framework to allow smooth international trade in generic ARVs (‘t Hoen et al. 2014). By 2016 generic competition had dropped the price of a year’s worth of AIDS drugs to less than US$100, or about 1 percent of its price in 2000 (Medecins Sans Frontieres 2016). The AIDS drug debate legitimised governments taking a more flexible approach to patent protection in order to protect public health, a major political and normative shift.

Discussion The political conflict over access to HIV medicines and IP rules can be seen as a first phase of global access to medicines politics—what we label ‘1.0’. Some observations regarding the politics of 1.0 are merited. First, access issues involved many different actors: governments in the global North and South, multilateral organisations (pri­ma­rily

616   Suerie Moon and Ellen ‘t Hoen the WTO and WHO, but also WIPO, UNDP, the UN Human Rights Commission/ Council, and UNCTAD), local and international NGOs, the pharmaceutical industry, academic experts, moral leaders, and foundations. At the turn of the millennium, the political alignments were relatively clear and strongly polarised: northern governments and the patent-holding originator pharmaceutical industry advocated for strict IP rules on one side; southern governments, generic pharmaceuticals, and NGOs pushed for flexible IP rules on the other; and multilaterals caught in the crossfire and various other non-state actors chose sides. Each of these actors brought different power resources to the political conflict. The North and industry had economic power, diplomatic muscle, a range of preferred experts, and influence over multilateral organisations by virtue of their major role as funders. The South and NGOs had the weight of global public opinion on their side, diplomatic strategies, a range of their own preferred experts, moral leaders, and strength in numbers in multilateral arenas. The Doha Declaration was the result of a combination of the uniquely alarming proportions of the HIV/AIDS crisis, the diplomatic manoeuvrings of southern governments, the political savvy of activists, and the coincidence of the post-9/11 anthrax crisis in the United States (Hein and Moon 2013). After Doha, as donor money began to flow towards expanding access to HIV treatment in developing countries, a shift in this political alignment became discernible. Both the Global Fund and PEPFAR, funded mainly by northern governments, purchased primarily generic medicines. Pharmaceutical companies were increasingly expected to make their medicines available and affordable in developing countries, at least for the few issues that had become global priorities: HIV, malaria, tuberculosis, and childhood vaccines. In low-income countries where no markets were at stake, the industry largely dropped its opposition to more flexible approaches to IP protection, particularly for HIV. For example the IFPMA did not oppose the request by LDCs at the WTO for extension of exemptions to the implementation of the TRIPS Agreement from 2006 to 2016, then later to 2033 (IFPMA 2015). The road was not always smooth; a number of legal disputes broke out in sub-Saharan Africa, Thailand, and Brazil relating to patents on medicines in the post-Doha years. But over the course of the ensuing decade what gradually solidified was what Hein and Moon (2013) have called an ‘access norm’—that is, widespread acceptance of the idea that medicines should be affordable to those who need them. After UNITAID decided to create the Medicines Patent Pool (MPP) in 2009 to negotiate voluntary licences with pharmaceutical companies to authorise generics in developing countries, the companies one-by-one came on board. Whilst civil society and UN pressure initially played a role in convincing them to do so, it is a remarkable shift that companies that were vehemently opposed to making their medicines widely affordable in the global South in 2001 voluntarily agreed to do so in over one hundred countries a decade later. As of 2016, all WHO-recommended ARVs were licenced to the MPP, and MPP licences reached 87 to 93 percent of people living with HIV in lowand middle-income countries (LMICs) (Juneja et al. 2017). In 2017 the MPP expanded its scope to include two other diseases, hepatitis C and tuberculosis, and began working to include all patented medicines on the WHO Essential Medicines List (Medicines Patent Pool 2018).

Global Politics of Access to Medicines   617 Whilst major shifts took place with respect to HIV and poorer countries, political conflicts remained fierce in other therapeutic areas (e.g., cancer) and in MICs, particularly in the emerging markets that were the main source of revenue growth for a ­globalising pharmaceutical industry. For example, in 2016 when the government of Colombia was contemplating a compulsory licence on a cancer drug (imatinib, sold by Novartis), a leaked diplomatic cable suggested that influential US officials had threatened to withhold funding for Colombia’s peace plan in response (Silverman 2016). Whether in conflicts over specific drug prices or on stringent IP provisions in bilateral/regional trade agreements, the two camps remained polarised. IP rules on medicines in MICs that manufactured generics, in particular India (and to a lesser extent China), had important implications for the rest of the developing world, which relied on imports for their low-cost generic medicine supply. We discuss these issues further in the following section. In addition to the primary political actors—governments, industry, and civil society— intergovernmental organisations and experts also influenced the politics of global access debates. As noted previously, WHO’s decisions to designate HIV medicines as ‘essential’ and to establish a system for quality assurance were both critical for enabling widespread use of lower-cost generic HIV medicines. WHO also provided an important arena for political debates to take place amongst governments and non-state actors. For example, stakeholders negotiated for two years before reaching a consensus on the 2008 WHO Global Strategy and Plan of Action (GSPoA) on Public Health, Innovation and Intellectual Property, which set out a course of work for all actors (World Health Assembly 2009). The extent to which the WHO Secretariat could support some of its member states in using measures such as compulsory licencing, however, was frequently the subject of heated debate at the annual gathering of health ministries at the World Health Assembly. WHO received very little funding to work on IP and medicine access—the work primarily fell to one staff person for about a decade—despite many WHA resolutions and the consensus GSPoA calling for such work. Overall, there was wide acceptance of WHO’s role as an arena for global health politics and a source of technical expertise, but on the most sensitive issues member states sought to control the organisation as much as possible (Moon 2014). Experts and expertise could also influence politics. Access to medicines often involved highly specialised and/or technical issues such as IP law, the economics of medicine innovation and production, pharmaceutical quality, and other regulatory matters. Experts could help to establish facts when politics threatened to obscure them. For example, it was important when the WTO secretariat clarified in writing that TRIPS did not limit compulsory licencing to situations of national emergency, a claim often advanced by the pharmaceutical industry. Groups of experts, such as committees and commissions, could also reframe political debates (Cooper and English  2005). For example, the 2004 report of the UK Commission on Intellectual Property Rights and 2006 report of the WHO Commission on Intellectual Property, Innovation and Public Health expanded the space for debate on the strengths and weaknesses of IP as a policy tool to achieve public objectives such as health or industrial development (CIPIH 2006;

618   Suerie Moon and Ellen ‘t Hoen Deere  2008). The 2012 report of the WHO Consultative Expert Working Group on Research & Development linked innovation and access issues inextricably together and boosted the attention given to alternate financing models for R&D (Røttingen and Chamas  2012). Such reports often reflected and solidified the evolution of political debates and also created space for new ideas to be considered. From 2000 until about 2015, the sum total of these developments was that an access norm became relatively well-established, and significant experimentation and increasing attention were devoted to medicine innovation. These developments laid the foundation for a more nuanced and complex political dynamic to emerge, what we call ‘access to medicines politics 2.0’.

Access to Medicines Politics 2.0 From its origins in the global movement for access to HIV treatment has grown a much broader global political debate on medicines. The politics of access to medicines has shifted in important ways, characterised by three major changes: an expansion from focusing on HIV and neglected disease to all diseases; a reframing of the debate from ‘access’ to ‘innovation and access’ that inextricably links access challenges to the current system of R&D; and a broadening of innovation and access concerns from developing countries to all countries, even the wealthiest. We discuss each of these shifts in turn, then consider their political implications. First, attention has expanded beyond HIV medicines to a much broader set of diseases for which new, highly priced medicines are being put on the market. Much of the concern has focused on the high prices of hepatitis C and cancer medicines. Hepatitis C medicines that could cure patients in twelve weeks were launched in the United States in 2013 at US$84,000 per treatment course, resulting in rationing amongst the sick and record-level profits for the seller, Gilead (Canary, Klevens, and Holmberg 2015; Iyengar et al.  2016). Cancer therapies, such as the Kymriah CAR-T treatment marketed by Novartis and priced at US$475,000, threaten the sustainability of health systems in high-income countries and are unimaginable for health systems in LMICs (Moon 2018). These prices have made headlines in Western media, prompted criticism from the highest political levels, and launched a flurry of policy proposals to address them. It can be expected that costly medicines for any disease offering significant therapeutic advance are likely to generate the same type of political attention. From genomic or personalised medicine to increasingly sophisticated reproductive technologies, advanced and costly technologies that offer healthier, longer lives to those who can pay will continue to be developed. Combined with the ageing of populations, this trend implies growing health spending and struggles in all countries to handle the financial strain on health systems. The second change is the shift in framing away from treating ‘innovation’ and ‘access’ as two separate issues to framing them as two sides of the same coin. As explained previously, debates on innovation—particularly that the R&D system failed to develop new

Global Politics of Access to Medicines   619 medicines for the neglected diseases of the poor—historically evolved on a parallel track with debates on access. One of the main responses to the problem of neglected diseases was the launch of non-profit PDPs that sought to develop new products for use in developing countries, at affordable prices, based on a logic of collaboration amongst the PDP, academia, governments, and industry. In some ways the PDPs were the polar opposite of the dominant for-profit R&D model, which sought to develop new products for the wealthiest countries, at the highest prices the market would bear, based on a logic of competition amongst firms. Non-profit R&D models with access as a core objective have matured as an alternate organisational form in the fifteen to twenty years they have existed; several brought new products to market and many had pipelines full of candidate products (Muñoz Tellez de Kieffer 2015). There has also been increased recognition that the R&D system fails to address not only the neglected diseases but also diseases that directly threaten all countries—in particular, pathogens of pandemic potential (prompted by the 2014 Ebola and 2016 Zika outbreaks) and antibiotics to combat the rise of antimicrobial resistance (AMR). Increased scrutiny of current business models for R&D has produced new thinking on how to change current practises to build access into the innovation process from the start, and there appears to be renewed interest in alternate business models for R&D that have affordability as a core objective. The concept of delinkage has become increasingly prevalent in debates over how to reform the existing innovation system (Love 2016). It is regularly adopted in UN and WHA resolutions, public debates, and policy proposals for new incentives for R&D (‘t Hoen 2017). The third major shift is an expansion of access challenges beyond developing countries, to affect all countries, even the wealthiest. In Switzerland, regularly amongst the five wealthiest countries in the world if ranked by Gross National Income (GNI) per capita, hepatitis C treatment was rationed for several years after the medicines were launched due to budget constraints. In the United States health spending has long grown faster than the overall economy (though it has stabilised in recent years),2 and spending on medicines is growing even faster than health sector spending (Quintiles IMS  2017). Medicine prices and the health benefit medicines deliver have become a political issue of growing importance. In LMICs the challenges remain immense. The LMICs face major financing gaps simply to provide a universal package of basic health services to their populations; in sixty-seven LMICs achieving universal health coverage by 2030 will require an estimated additional investment of USD41–58 per person per year, which will require major increases above current investment levels (Stenberg et al.  2017). Expanding these budgets to pay for a growing arsenal of medicines and other health technologies is a tall order. At the same time, development assistance for health has hit a plateau after fifteen years of record growth (IHME 2016) and is likely to shift towards low-income countries. Overall, donor funds to finance medicines will become more scarce, especially in MICs. In many MICs, however, health spending is an increasing proportion of the economy. For MICs shouldering the full burden of medicine financing, there will be a strong incentive to push even harder for policy measures that give governments leverage to reduce drug prices. The right to health is included in the constitutions of

620   Suerie Moon and Ellen ‘t Hoen a number of countries (Hogerzeil et al. 2006), such as South Africa and Brazil, which is an important lever for ensuring access to medicines at the national level but also implies growing future health expenditures.

Discussion Taken together, these three shifts have important implications for the global politics of access to medicines. First, there is likely to be a gradual erosion of the North-South polarisation that has long dominated debates on access to medicines. In Europe, where widespread publicly financed health insurance systems mean that rising medicine prices directly impact government budgets, there has been high-level political criticism of the traditional R&D system and resulting high prices. For example, the European Council Conclusions of June 2016 expressed concern about the sustainability of medicine pricing trends and set in motion a process of review and possible revision of EU pharmaceutical incentive mechanisms (Council of the European Union 2016). This was a significant shift away from what has long been a maximalist European Union position in international IP negotiations. More specifically, the Dutch trade and health ministers in 2016 called for increased transparency on R&D costs and drug pricing, new business models for R&D, and no TRIPS-plus measures in new regional trade agreements (Ploumen and Schippers 2016). Instead of North-South politics, left-right divides that cut across all countries may take prominence, with left-leaning actors arguing for a greater role for governments in funding and regulating innovation and pricing, and right-leaning groups arguing for a smaller one. If so, the politics will become more complicated, with political alliances forming across groups of like-minded governments and non-state actors rather than the simple two-camp positioning of the past. This also underscores the enduring importance of domestic elections. The shift from access to medicines being considered a developing country issue to being a global issue may also open the door to more significant reform of the global R&D system. Northern governments have far greater leverage to change the funding, incentives, and regulations that govern innovation processes because they remain the main source of public R&D investment and the largest medicine markets. More governments may demonstrate new political willingness to reform the R&D system as policymakers directly feel the budget implications of high drug prices. In addition, the search for new R&D business models that can jointly deliver innovation and access will challenge established political alignments. Measures to control medicine prices, including but not limited to the use of IP flexibilities, have run directly counter to the interests of patent-holding pharmaceutical companies. However, proposals for R&D reform have tended to emphasise rewarding innovators (including but not limited to corporations) for useful new inventions, albeit through means other than market monopolies. Industry decision-makers willing to test new models of R&D may find themselves aligned with NGOs, academics, and governments calling for the same.

Global Politics of Access to Medicines   621 Furthermore, the gradual rise of MICs will also shape the politics of innovation and access to medicines. Some MICs have increased their financial contributions to international R&D efforts. For example, the South African government has funded the Global Antibiotics Research and Development Partnership (GARDP), a PDP launched in 2017 to spur R&D for new medicines to combat antimicrobial resistance. Contributing funding to R&D may shift the framing of access debates away from ‘charity’ or ‘development aid’ towards a frame of ‘shared responsibility’ or ‘cooperation.’ MICs are also the site of increasing domestic R&D activities. In 2017 China became the second largest source of new international patent applications, surpassing Japan and trailing only the United States (WIPO 2018). Domestic investment in R&D in China has grown rapidly, more than doubling since 2000 to surpass 2 percent of GDP in 2016—matching the average R&D investment ratio in Organisation for Economic Co-operation and Development (OECD) countries, and approaching US R&D investment in absolute terms.3 China and other MICs also face significant pressure to expand healthcare provision, including access to new medicines, as their economies grow. MICs’ governments may face competing objectives: to promote their burgeoning domestic biopharmaceutical industries and to ensure access to medicines for their domestic populations. Again, the implication is a more complex political dynamic, with domestic political alignments perhaps becoming more important than international North-South divides. Finally, changes in the pharmaceutical industry itself are also likely to complicate global medicine politics. Some in the industry have already signalled their willingness to consider new R&D business models, most prominently in the area of antibiotics. In addition, biotechnology firms have become an increasingly important source of innovation, including many small and medium enterprises (SMEs) that spin off from academic laboratories. Testing new R&D business models may be more feasible with SMEs, both because of the smaller scale of investment necessary and because many rely on public grants (or venture capital investment) to keep their doors open. At the same time, there has been significant consolidation in the industry, including the acquisition of some major Indian generic firms by large multinationals (PriceWaterhouseCoopers 2018). Some generic firms may emphasise collaboration over competition with patentholders as a result. Market concentration of the largest firms may also further concentrate political power of the pharmaceutical industry and its ability to influence public policies and debates. As with governments, on balance the politics appears set to become more complex.

Conclusion The question of how societies organise the research, development, pricing, and supply of health technologies profoundly shapes who does and does not benefit from advances in science and technology. These life or death questions have generated fierce political conflict, which has in turn shaped the flows of billions of dollars in public and private

622   Suerie Moon and Ellen ‘t Hoen resources. Innovation and access to medicines are likely to remain enduring issues for both global and domestic politics in the decades to come. The rise of personalised medicine, genomics, and other technological advances hold out the prospect of life-changing inventions but also wrenching ethical debates about prices and access (amongst other issues). The relevance of these debates will only increase with the ageing of populations, growth of health spending in countries at all levels of development, and globalisation of pharmaceutical research and production, particularly to MICs. The experience of the past several decades suggests that a world in which medicines are increasingly sophisticated, but available only to the lucky few, will not be politically sustainable. The politics that shapes how national and global societies ultimately respond to these challenges is likely to become increasingly complex in this ‘2.0’ era.

Acknowledgements We are grateful to Danielle Mae Navarro for research assistance in preparing this manuscript.

Notes 1. Authors’ calculations of data from the World Bank, https://datacatalog.worldbank.org. 2. Data on health spending since 1960 from US Centers for Disease Control and Prevention, http://www.cdc.gov/nchs/hus/healthexpenditures.htm#total. 3. Data on R&D investment in OECD countries from the OECD, https://data.oecd.org/rd /gross-domestic-spending-on-r-d.htm.

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Global Politics of Access to Medicines   623 Chetley, Andy. 1986. ‘Health Action International: A Profile of the Action Network That Holds the Pharmaceutical Industry Accountable.’ New Internationalist, November 5, https://newint .org/features/1986/11/05/action. Commission on Health Research for Development, ed. 1990. Health Research: Essential Link to Equity in Development. New York, N.Y: Oxford University Press. http://www.cohred.org /downloads/open_archive/ComReports_0.pdf. Commission on Intellectual Property Rights, Innovation and Public Health (CIPIH). 2006. ‘Public Health, Innovation and Intellectual Property Rights.’ Geneva: World Health Organization (WHO). http://www.who.int/intellectualproperty/report/en/index.html. Cooper, Andrew  F., and John English. 2005. ‘International Commissions and the Mind of Global Governance.’ In International Commissions and the Power of Ideas, edited by Ramesh Thakur, Andrew F. Cooper, and John English, 1–26. Tokyo, Japan: United Nations University Press. https://collections.unu.edu/eserv/UNU:2456/pdf928081110X.pdf. Commission on Health Research for Development, ed. 1990. Health Research: Essential Link to Equity in Development. New York: Oxford University Press. http://www.cohred.org /downloads/open_archive/ComReports_0.pdf Council of the European Union. 2016. ‘Council Conclusions on Strengthening the Balance in the Pharmaceutical Systems in the EU and Its Member States—Consilium.’ https://www. consilium.europa.eu/en/press/press-releases/2016/06/17/epsco-conclusions-balance -pharmaceutical-system/. Currat, Louis J., Adnan A. Hyder, Thomas C. Nchinda, and Elizabeth Carey-Bumgarner. 1999. The 10/90 Report on Health Research 1999. Geneva, Switzerland: Global Forum for Health Research. https://www.files.ethz.ch/isn/20437/1090.99_FullText.pdf. ‘Declaration of Alma-Ata: International Conference on Primary Health Care.’ 1978. Alma-Ata, USSR, September 6–12. https://www.who.int/publications/almaata_declaration_en.pdf. Deere, Carolyn. 2008. The Implementation Game: The TRIPS Agreement and the Global Politics of Intellectual Property Reform in Developing Countries. Oxford: Oxford University Press. Drahos, Peter. 2010. ‘“IP World”—Made by TNC Inc.’ In Access to Knowledge in the Age of Intellectual Property, edited by Amy Kapczynski and Gaëlle Krikorian, 197–216. New York: Zone Books. Duran, Denizhan, and Rachel Silverman. 2013. ‘The Global Fund to Fight AIDS, Tuberculosis and Malaria.’ Background paper prepared for the Working Group on Value for Money: An Agenda for Global Health Funding Agencies. https://www.cgdev.org/sites/default/files /Global%20Fund%20Background%20Paper.pdf. Fortunak, Joseph M., and O. A. C. Antunes. 2006. ‘ARVs Production in Brazil—An Evaluation.’ Rio de Janeiro: ABIA/MSF. http://www.deolhonaspatentes.org.br/media/file/Publicacoes /ARV.pdf. GAVI, The Vaccine Alliance. 2017. ‘2017 Annual Financial Report.’ https://www.gavi.org/funding/ financial-reports/. Hein, Wolfgang, and Suerie Moon. 2013. Informal Norms in Global Governance: Human Rights, Intellectual Property Rules and Access to Medicines. Aldershot, UK: Ashgate. Hogerzeil, Hans V., Melanie Samson, Jaume Vidal Casanovas, and Ladan Rahmani-Ocora. 2006. ‘Is Access to Essential Medicines as Part of the Fulfilment of the Right to Health Enforceable through the Courts?’ The Lancet 368 (9532): 305–311. doi:10.1016/S0140-6736(06)69076-4. Hordijk, Lucien. 2017. ‘Deze Farma-Activist Buigt Regels Zonder Ze Te Breken: En Redt Er Levens Mee.’ De Correspondent, February 11. https://decorrespondent.nl/6174/deze-farma-activist -buigt-regels-zonder-ze-te-breken-en-redt-er-levens-mee/1395404441046-b8d6b5cd.

624   Suerie Moon and Ellen ‘t Hoen IHME. 2016. ‘Financing Global Health 2015: Development Assistance Steady on the Path to New Global Goals.’ Seattle, WA: Institute for Health Metrics and Evaluation. http://www .healthdata.org/sites/default/files/files/policy_report/FGH/2016/IHME_PolicyReport_ FGH_2015.pdf. International Federation of Pharmaceutical Manufacturers and Associations (IFPMA). 2015. ‘LDCs Request for Extension of TRIPS Implementation.’ https://www.ifpma.org/resource -centre/LDCS-request-for-extension-of-trips-implementation/. Iyengar, Swathi, Kiu Tay-Teo, Sabine Vogler, Peter Beyer, Stefan Wiktor, Kees de Joncheere, et al. 2016. ‘Prices, Costs, and Affordability of New Medicines for Hepatitis C in 30 Countries: An Economic Analysis.’ PLOS Medicine 13 (5): e1002032. doi:10.1371/journal.pmed.1002032. Juneja, Sandeep, Aastha Gupta, Suerie Moon, and Stephen Resch. 2017. ‘Projected Savings through Public Health Voluntary Licences of HIV Drugs Negotiated by the Medicines Patent Pool (MPP).’ PloS One 12 (5): e0177770. Love, James. 2016. ‘An Economic Perspective on Delinking the Cost of R&D from the Price of Medicines.’ Discussion paper. UNITAID. https://unitaid.eu/assets/Delinkage_Economic_ Perspective_Feb2016.pdf. Lu, Ye, Patricia Hernandez, Dele Abegunde, and Tessa Edejer. 2011. ‘Chapter 4: Medicine Expenditures.’ In The World Medicines Situation 2011, edited by World Health Organization (WHO), 1–34. Geneva: World Health Organization (WHO). http://apps.who.int /­medicinedocs/documents/s18767en/s18767en.pdf. Medicines Patent Pool. 2018. ‘The Medicines Patent Pool 2018–2022 Strategy.’ https://­ medicinespatentpool.org/who-we-are/strategy/. Medecins Sans Frontieres. 2016. Untangling the Web of Antiretroviral Price Reductions. 18th ed. https://msfaccess.org/untangling-web-antiretroviral-price-reductions-18th-edition. Moon, Suerie. 2009. ‘Medicines as Global Public Goods: The Governance of Technological Innovation in the New Era of Global Health.’ Global Health Governance 2 (2). http://www .ghgj.org/moon2.2medecinespublicgood.htm. Moon, Suerie. 2014. ‘WHO’s Role in the Global Health System: What Can Be Learned from Global R&D Debates?’ Public Health 128 (2): 167–172. Moon, Suerie. 2017. ‘Powerful Ideas for Global Access to Medicines.’ New England Journal of Medicine 376 (6): 505–507. Moon, Suerie. 2018. ‘Removing the Blindfold on Medicines Pricing.’ BMJ 360 (February): k840. doi:10.1136/bmj.k840. Moon, Suerie, and Thirukumaran Balasubramaniam. 2018. ‘The World Trade Organization: Carving Out the Right to Health for Access to Medicines and Tobacco Control.’ In Human Rights in Global Health: Rights-Based Governance for a Globalizing World, edited by Benjamin Mason-Meier and Lawrence  O.  Gostin, 375–396. New York, United States of America: Oxford University Press. https://www.oxfordscholarship.com/view/10.1093 /oso/9780190672676.001.0001/oso-9780190672676-chapter-18. Muñoz Tellez de Kieffer, Viviana Carolina. 2015. ‘Institutions, Innovation and Public Health.’ Lausanne, Ecole Polytechnique Federale de Lausanne. doi:10.5075/epfl-thesis-6566. https://infoscience.epfl.ch/record/206859 Musgrove, P. 1993. Investing in health: the 1993 World Development Report of the World Bank, 27(3): 284–286. Ploumen, Lilianne, and Edith Schippers. 2016. ‘Better Life through Medicine—Let’s Leave No One Behind.’ The Lancet, November 7. doi:10.1016/S0140-6736(16)31905-5.

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chapter 32

Non- Com m u n ica bl e Diseases a n d Gl oba l Hea lth Politics Roger Magnusson

Non-communicable diseases (NCDs) are responsible for nearly forty million deaths each year (GBD 2015 Mortality and Causes of Death Collaborators 2016). Around 80 percent of these NCD deaths are caused by cardiovascular disease (CVD), cancer, chronic respiratory diseases, and diabetes—diseases linked by a cluster of modifiable behavioural and physiological risk factors, including tobacco use, harmful use of alcohol, obesity, unhealthy diets, high blood pressure, and lack of physical activity (see table 32.1). Since 1980, average life expectancy at birth has risen by ten years, and as a result NCDs have become ‘the diseases of those with longer lives’ (Bollyky 2012). Despite accounting for around 70 percent of global deaths each year, NCDs have been spectacularly unsuccessful in attracting development funding for management and prevention in low- and middle-income countries (Nugent 2016). For example, in 2015 development assistance for health (DAH) for NCDs represented only 1.3 percent of total DAH. Whilst DAH for NCDs grew by more than 8 percent over the period 2000–2015, it grew at a slower rate than other areas of health investment, and indeed fell by 3.4 percent in 2015 (IHME 2015, 27, 65–67). Despite growing international diplomatic coordination around NCDs, the reality is that the future of NCDs will depend substantially on countries’ capacity for self-help (Cassels 2015). This chapter sets the scene by briefly describing how NCDs have emerged as a global health challenge. Whilst NCDs affect individuals and are seen by some as the consequence of personal failings and lifestyle choices, their global health impact is better understood by focusing on the demographic, market, and political conditions that have resulted in rising rates of behavioural and physiological risk factors across the population, including in low- and middle-income countries. This chapter reviews the mixed success of global efforts to create a future less burdened by NCDs. To do this, I present a simple model for analysing the activities of global forums that have the capacity to drive

628   Roger Magnusson Table 32.1  Mortality from NCDs in 2015 Selected Modifiable Behavioural and Physiological Risk Factors Contributing to Death

Selected Causes of Death

Metabolic risks: 16.9 million

Non-communicable diseases: 39.8 million

High fasting plasma glucose: 5.2 million

Cardiovascular disease: 17.9 million

High cholesterol: 4.3 million

Cancers: 8.8 million

High blood pressure: 10.7 million

Chronic respiratory diseases: 3.8 million

High body mass: 4 million

Diabetes: 1.5 million

Dietary risks: 12.1 million

Transport injuries: 1.5 million

Diet high in sodium: 4.1 million

Cf. HIV/AIDS and tuberculosis: 2.3 million

Tobacco smoke: 7.2 million Alcohol use: 2.3 million Insufficient physical activity: 1.6 million Cf. unsafe sex (all causes): 1.5 million Source: GBD 2015 Risk Factor Collaborators (2016)

changes at the country level, including the World Health Organization (WHO) and United Nations General Assembly (UNGA). Two important, overarching questions to consider are: To what extent has the global political response to NCDs provided a catalyst for the changes that will be necessary at the country level to wind back mortality and morbidity? If prospects for future development assistance for addressing NCDs remain grim, where are the opportunities for making progress?

Why Have NCDs Become a Global Health Challenge? Since 1960, life expectancy at birth has improved dramatically, rising thirteen, twenty-three, and twenty-two years in high-, middle-, and low-income countries, respectively, reaching eighty-one, seventy-one, and sixty-one years in 2014 (World Bank 2016). These improvements in life expectancy reflect the relative success of global efforts to reduce child and maternal mortality and mortality from communicable diseases. The result is more people ‘dying at lower rates and living to older ages’ (IHME 2016, 24). However, running in parallel with this good news story is the global rise in ­lifestyle-related risk factors, including tobacco use, obesity, unhealthy diets, harmful use of alcohol, drug use, lack of physical activity, high blood pressure, and high blood sugar

Non-Communicable Diseases   629 levels. These risk factors—and the NCDs they cause—threaten healthy ageing and cause premature mortality. At the global level, prevention and better treatment of NCDs have progressively reduced the age-standardised rate of disability adjusted life years (DALYs) from NCDs. On the other hand, the overall rate of increase of the adult population in countries that have undergone the demographic transition—and now have more adults living to older ages—means that the absolute burden of NCDs is rising and will continue to do so (GBD 2015 Mortality and Causes of Death Collaborators 2016; IHME 2016, 35). Two points about the global rise in NCDs deserve emphasis. First, NCD risk factors are driven by markets: for tobacco, alcohol, highly processed foods, and sugary beverages (Moodie et al. 2013; Stuckler et al. 2012; Monteiro et al. 2013). These markets have expanded rapidly in developing countries as a result of trade and investment liberalisation policies that lead to increased levels of direct foreign investment, imports, and advertising (Baker, Kay, and Walls 2014; Labonté, Mohindra, and Lencucha 2011; Friel et al. 2013; Hawkes, Chopra, and Friel 2009). For example, Lopez and colleagues observed that reductions in tariffs across forty-four low- and middle-income countries were associated with an increase in imports of sugar-sweetened beverages (SSBs); an increase in imports, in turn, was associated with greater sales of SSBs (Lopez et al. 2017). Whilst these associations do not prove causation, the authors conclude that it is highly likely that reduced tariffs promote higher consumption of SSBs, and that targeted, nondiscriminatory taxes are important tools for addressing the adverse impacts of free trade agreements on health. The growth in markets that contribute to NCDs points to an important area of scholarship that investigates how countries can exercise the health sovereignty that is required to implement effective preventative policies whilst avoiding challenges under trade and investment agreements (Thow and McGrady 2014; Voon and Mitchell 2014; Voon 2013). Australia’s experience defending a complaint about its tobacco plain packaging legislation (Permanent Court of Arbitration 2015) and Uruguay’s experience defending a complaint about national legislation mandating large-sized health warnings on tobacco packages and restrictions on tobacco brand variants (International Centre for Settlement of Investment Disputes 2016) illustrate the willingness of tobacco multinationals to challenge legislation that threatens tobacco sales and profits. The fact that Australia and Uruguay were both successful is a substantial victory for public health, but still only part of the story. Defending ultimately baseless claims is expensive; the need to do so provides an object lesson for risk-averse, resource-poor governments. Small countries are at a particular disadvantage. Pacific Island countries and territories (PICTs) reflect the dire health consequences of the global trade in processed foods, tobacco, and increasingly, alcohol. In Fiji and Samoa, trade liberalisation policies included winding back export taxes, import tariffs, and import substitution policies. In combination with the influence of direct foreign investment, export promotion (cash cropping, resulting in reduced subsistence farming and cultivation of traditional food crops), and disaster food aid, these policies led to increased consumption of refined cereals, meats, fats, oils, and processed foods (Thow et al. 2011; Snowdon and Thow 2013). Emblematic of the discipline that trade and

630   Roger Magnusson investment agreements can exercise over national policies was the requirement for Samoa to reverse its ban on fatty turkey tails as a condition of its accession to the World Trade Organization (WTO 2011; Thow et al. 2017). PICTs are now in the grip of an NCD disaster (Magnusson and Patterson 2015). Combined rates of overweight and obesity in some PICTs exceed 80 percent: Tonga, 86 percent; Samoa, 84 percent; and Kiribati, 79 percent (Ng, Fleming, et al. 2014). In a number of PICTs, around one-third of the population has diabetes (Tokelau, 37 percent; Federated States of Micronesia, 35 percent; and Marshall Islands, 35 percent; Chan et al. 2014). Some PICTs spend a substantial share of their national health budgets paying for their citizens to access dialysis in third countries. Other PICTs have world-leading smoking rates; for example, in Kiribati, over 54 percent of men and 31 percent of women are daily smokers (Ng, Freeman, et al. 2014). In Samoa, daily smoking in males fell from 76 percent to 36 percent over the period 1978–2013, yet remains nearly three times as high as smoking rates in Australia and New Zealand (Linhart et al. 2017). In addition to NCDs, many PICTs face a rising burden from injuries, often linked to alcohol consumption, and a lingering burden of communicable diseases, creating a crippling ‘triple burden’ of disease. The Pacific NCD crisis leads to the second point about the global rise of NCD risk factors. NCDs are a major driver of inequality, both within and between countries. For example, a report from the Council on Foreign Relations (2014) demonstrates that NCDs are rising faster in younger populations in low- and middle-income countries than they are in high-income countries, exacerbating health inequalities. Between 1990 and 2010, DALYs from all NCDs rose by 9 percent in high-income countries and 18 percent in upper-middle-income countries, but by 38 percent and 42 percent in lower-middle-income and low-income countries, respectively (Council on Foreign Relations 2014,11). Similar themes emerge from A Race Against Time (Leeder et al. 2004; Harikrishnan et al. 2014), which assessed the likely future of CVD in the BRICS countries (Brazil, Russia, India, China, and South Africa). The authors demonstrate how significant increases in population in these countries, particularly in the working-age population (ages thirty-five to sixty-four), combined with modest increases in rates of CVD risk factors in these populations, will create a crippling burden of future disease. Until around 2025 there is a window of opportunity, whilst the population is younger overall and the number of dependents per working adult is lower, to implement population-wide preventative measures, strengthen health systems, treat NCDs cost-effectively, and cope with growing demand (Raymond 2003). Failure to do so will cause significant economic harm by undermining future productivity, especially amongst the rising middle class of skilled workers who are expensive to train. Emblematic of the future economic challenge of NCDs is the global rise of diabetes, expected to increase from 382 million people in 2013 to 592 million by 2035 (Guariguata et al. 2014). NCDs also exacerbate health inequalities within countries. There is increasing evidence that NCDs and their risk factors occur at higher rates amongst those with lower levels of

Non-Communicable Diseases   631 income and education (Sommer et al. 2015; Di Cesare et al. 2013; Vellakkal et al. 2013; UNDP 2013) and are a driver of poverty in low-income settings (UNDP 2015; Engelgau et al. 2011, 28–31). For example, when people smoke and drink, this dissipates household income (Barber, Ahsan, Adioetomo et al. 2008). The percentage of income diverted can be substantial, reducing spending on necessities like food, education, and healthcare (Block and Webb 2009). High out-of-pocket fees may be required for treatment and medications for NCDs, especially in countries without a healthcare safety net. Illness also creates opportunity costs, forcing income earners out of work or obliging children to assume carer roles, interrupting schooling and perpetuating the poverty cycle.

The Challenges of Building a Global Movement for Action on NCDs In the early years of the new millennium, academic papers and WHO reports began to signal the significance of NCDs as a development challenge (Beaglehole and Yach 2003; Strong et al. 2005; WHO 2005a). NCDs were not included in the Millennium Development Goals (MDGs), the United Nations (UN) development blueprint for 2000–2015, rendering them less visible and excluded from MDG budgets. NCDs were also competing with established priorities, including maternal and child health, HIV, TB, and malaria (Morrison 2011). Until 2005, mortality rates from HIV/AIDS were still rising (IHME 2016, 27–28), whilst in 2007–2009, the global financial crisis shrank the budgets of both developing countries and their development partners. Nevertheless, the news was not all bad. The World Bank’s influential report Curbing the Epidemic (1999) made the economic case for tobacco control and came at a crucial time, as negotiations commenced for a Framework Convention on Tobacco Control (FCTC). It is worth pointing to elements already in place by the time FCTC negotiations began: a high-level program on tobacco control within WHO and its regional offices (the Tobacco Free Initiative); the Ad Hoc Interagency Task Force on Tobacco Control, which coordinated work on tobacco control within the UN system; a global civil society movement for tobacco control (the Framework Convention Alliance); and through partnership with the US Centers for Disease Control and Prevention, the beginnings of the Global Tobacco Surveillance System (WHO 2009a). The WHO FCTC was adopted by the World Health Assembly in 2003 and entered into force on February 27, 2005. However, a variety of factors stood in the way of a broader, collective response to NCDs that extended beyond tobacco control. NCDs were a ‘slow motion disaster’ (Chan 2011), yet unlike HIV/AIDS, they were not seen as an infectious threat inflicting immediate and indiscriminate harm on young and old (Morrison 2011). NCDs were caused by behavioural risk factors—smoking, drinking, eating—feeding the assumption that lifestyle modifications, education, and personal responsibility were the appropriate

632   Roger Magnusson interventions. Although public health scholars might regard diet-, alcohol-, and tobacco-related NCDs as ‘industrially created’ epidemics (Moodie et al. 2006; Malone 2010; Stuckler and Nestle 2012; Moodie et al. 2013; Stuckler et al. 2012; Wiist 2011), the multiple determinants of diet-related NCDs and the long period of exposure and consumer behaviour preceding them tended to cloud assumptions about causality and attribution of responsibility (Maher and Sridhar 2012, 4). This benefited, and continues to benefit, the food and beverage industries. Scholars have pointed to the way in which neo-liberal ideology frames public health challenges as predominantly individualistic concerns, privileging lifestyle-related interventions and health promotion over the adoption of healthy public policies by governments (Ayo 2012). An excessively individualist perspective, in turn, has a distorting effect on one’s understanding of public policy, feeding the assumption that a ‘public health response’ can only mean appealing to individuals to consciously take steps to reduce their personal risk. Neo-liberalism’s key tenets (including minimal government intervention, anti-welfarism, extreme deference to markets, and personal responsibility), and its success in shifting public responsibilities from the public to the private sphere (Clarke 2004), remain a formidable threat to global progress on NCDs in the future. Despite these challenges, the lead-up to the UN General Assembly’s High-Level Meeting on the Prevention and Control of Non-communicable Diseases in 2011 saw significant progress in making the economic case for governments to implement a core set of cost-effective policies for prevention and treatment (Beaglehole et al. 2011; WHO and World Economic Forum 2011; World Bank 2011; WHO 2010a, 2011). This work was driven by academic networks (reflected, for example, in the Lancet’s series on chronic diseases, and later obesity), and by publications from WHO, later the World Bank, and other partners. WHO estimated the cost of a basket of interventions to reduce tobacco use and harmful use of alcohol and to improve diet and physical activity levels at 4 percent of current health spending in low-income countries, 2 percent in lower-middle-income countries, and < 1 percent in upper-middle-income countries (WHO 2011). The intention was to illustrate that solutions to NCDs exist, and with collective commitment, are within reach of all countries. The identification of feasible solutions was critical, given claims about the scale of the NCD crisis. NCDs were responsible for over 60 percent of global deaths in 2005, according to WHO, with an expected 17 percent increase by 2015 (WHO 2005a). NCDs were not a new problem in health development; they were health development. NCDs might have merited a fundamental rethinking of the conceptual framework for DAH; the more immediate problem, however, was to get NCDs on the agenda at all. Despite growing understanding of the reality of the problem and the existence of plausible policy responses, scholars point out that public policy change is not a purely rational process. An important literature identifies critical features that influence whether evidence translates into political action (Clarke, Swinburn, and Sacks 2016; Cullerton et al. 2016; Shiffman and Smith 2007; Huang et al. 2015; Baker et al. 2017;

Non-Communicable Diseases   633 Knaggård 2015). At the global level, these features include the incentives and mandates of actors (including governments, donors, and global institutions), access to global forums for mobilising political support, the existence of coalitions pressing for change, power relations between actors, and other factors that make up what is often called the ‘policy context’ (Geneau et al. 2010). Prior to the high-level UN meeting in 2011, the major forum for global action on NCDs was the World Health Assembly (WHA). WHO’s response was dominated by risk-factor-specific strategies: the WHO Framework Convention on Tobacco Control (WHO 2005b) and a number of non-binding instruments. These included the Set of Recommendations on the Marketing of Foods and Non-alcoholic Beverages to Children (WHO 2010b) and the global strategies on infant and young child feeding (WHO 2003a); diet, physical activity, and health (WHO 2004); and harmful use of alcohol (WHO 2010c). The exception was the 2008–2013 action plan for prevention and control of NCDs (WHO 2009b), now replaced by the 2013–2020 action plan (WHO 2013a). Both documents collated evidence; stated the case for action; and identified actions for member states, the WHO Secretariat, and international partners. Throughout the MDG era, NCDs compared poorly to HIV/AIDS in terms of the ability of advocates and affected communities to project them as an issue of health justice. This remains a substantial obstacle to global advocacy efforts. The element of outrage that was crucial to mobilising political action on HIV/AIDS is largely absent. Today’s NCD advocates point to the social determinants of health inequalities but tend not to burst onto the stages of national and international conferences, drowning out the voices of politicians and transforming technical issues into visceral, political demands. The NCD Alliance, representing the major NCDs, including CVD, cancer, diabetes, and respiratory diseases, was formed prior to the 2011 high-level meeting. However, patients were ‘not present as a core social or political base’ (Morrison 2011). In explaining why NCD advocates have struggled to get their message across, Maher and Sridhar (2012) refer to Shiffman’s (2009) explanation of why some global health issues attract attention whilst others languish. For social constructionists like Shiffman, global health problems like HIV, polio, or NCDs do not have any inherent priority or significance; rather, the attention an issue receives, whilst not unrelated to underlying material conditions, is ‘always mediated by social interpretations’ (Shiffman 2009, 608). From a social constructionist perspective, the ‘core activity’ of global health advocates is ideational: health advocates must advance truth claims about the problem and its solutions that resonate with the values and shared interpretations of political leaders and those who control resources. In this view, global health is a competitive (and brutal) process of ‘portraying and communicating severity, neglect, tractability and benefit in ways that appeal to political leaders’ social values and concepts of reality’ (Shiffman 2009, 610). Moreover, the key to sustaining issue ascendancy lies in the creation of formalising institutional arrangements that assist in mobilising resources, implementing programs, and sustaining the way in which the issue is framed and portrayed. For example, in the case of HIV/AIDS, a success story in global health advocacy, political priority

634   Roger Magnusson is both reflected in and sustained by global institutional infrastructure, including the United Nations Programme on HIV/AIDS (UNAIDS), The Global Fund to Fight AIDS, Tuberculosis and Malaria, and the US President’s Emergency Plan for AIDS Relief (PEPFAR). In applying these insights to NCDs, Maher and Sridhar point out that NCD advocacy has been dominated by technical considerations—generating good data and credible, cost-effective solutions—as if these were enough to unlock wallets and galvanise political commitment. NCDs have been a ‘case study in poor branding’, they argue, since the frames that have predominated in making the case for the importance of NCDs lack salience, or a sufficient connection with people’s lives (Maher and Sridhar 2012, 4; Shiffman 2009, 609). The preoccupation with generating credible data may reflect a certain defensiveness in the face of the vastly superior resources and capacity of the tobacco, alcohol, food, and drink industries to peddle misinformation. But it has come at a price. The NCD movement lacks frames of reference to which people can relate in emotional terms. Whilst this does not imply that NCD advocates should somehow seek to replicate the gaunt-faced young men and babies who shaped perceptions of AIDS in the 1980s, the underlying issue remains. Allen points out, ‘Photographs of middle-aged obese smokers suffering from (what are perceived as) self-inflicted health conditions do not naturally arouse charitable sentiment’ (Allen 2016). Added to this is the term itself. NCDs is not only a movement defined by what it is not: diseases that are not communicable. It is also a movement framed by a label that denies the key message that might help to generate priority—that is, the fact that the risk factors for these diseases are both socially communicable and transmitted globally to vulnerable populations for the sake of profit (Maher and Sridhar 2012, 4; Allen 2016). The challenges of creating a global movement for NCDs should not overshadow what has been achieved. In terms of actors, the Caribbean Community (CARICOM) deserves special credit for its strategic advocacy for NCDs. This includes the CARICOM heads of government meeting on the impact of NCDs in the region, which led to the Port-of-Spain declaration (CARICOM 2007) and subsequently to the Communiqué by Commonwealth Heads of Government, which called for a global summit on NCDs (CHOGM 2009). In 2010 the UN General Assembly adopted a resolution tabled by Trinidad and Tobago scheduling the high-level meeting on NCDs in September 2011 (Hassell and Hennis 2011). In the end, the declaration from the high-level UN meeting was significant in confirming NCDs to be a ‘challenge of epidemic proportions’ and in acknowledging the ­primary role and responsibility of governments in meeting the challenge (UNGA 2011). Overshadowing the importance of the declaration itself, however, was the fact that the meeting constituted a change in the locus of governance. Since 2011 NCDs have become a shared responsibility of WHO, the UN General Assembly, and other willing partners. The declaration recognised that effective action on NCDs requires a whole-of-government response, with shared responsibility across ministries, sectors, and levels of government, as well as a whole-of-society effort, requiring effective engagement with civil society, the private sector, and academia.

Non-Communicable Diseases   635

Progress in the Global Response to NCDs since the High-Level UN Meeting The high-level meeting of the UN General Assembly in 2011 was the first time that NCDs reached the agendas of heads of state. The significance of this political opportunity, however, depended on the capacity of the UN system to institutionalise NCD ­prevention and control within the broader UN development agenda (Alleyne, Stuckler, and Alwan 2010). This chapter presents a simple framework for taking stock of global action on NCDs since the 2011 high-level UN meeting. The framework highlights some of the pathways— both used and neglected—through which global actions can lead to improvements in national health outcomes. These pathways include the development of (1) normative instruments and policy guidance and (2) political accountability mechanisms by global institutions, and (3) the provision of economic and material support for implementation of policies and programs by globally significant donors (see table 32.2). Other pathways, such as the strategic use of public communications and the media, and capacity-building —particularly in the use of law and regulation to implement priority policies for NCDs (Magnusson, McGrady, et al. 2019), are not discussed in detail in this chapter.

Normative Instruments and Policy Guidance

Normative global instruments include recommendations, guidelines, codes of conduct, strategies, action plans, and status reports; these are typically the product of evidence gathering and consultation processes and are intended to encourage legislative, executive, and political actions by countries. Much of WHO’s leadership prior to and since the high-level UN meeting in 2011 has focused on generating a suite of normative documents that is intended as a catalyst and resource for national action. In the case of the WHO FCTC, parties have assumed a legal obligation to implement national policies and laws that comply with its requirements. In most circumstances, however, normative instruments are ‘soft power’ instruments that assist countries in identifying national priorities and implementing effective policies. Supported by WHA and UN General Assembly resolutions, the implementation of policy recommendations is one of the most obvious ways that the work of these forums translates into changes at the country level. The most significant global normative instrument on NCDs is WHO’s (2013a) Global Action Plan for Prevention and Control of NCDs 2013–2020, adopted by the WHA in 2013. Appendix 3 of this document, updated and endorsed by WHA in 2017, identifies a menu of policy options for governments, including a subset of highly cost-effective ‘best buys’ (WHO 2017a). Other influential documents include the Report of the Commission on Ending Childhood Obesity (WHO 2016a), the Report of the WHO Independent HighLevel Commission on NCDs (WHO 2018a), the revised ‘Global Strategy for Women’s,

636   Roger Magnusson Table 32.2  Framework for Analysing How Global Actions in Health May Influence National Actions Pathway

Global Actions, Activities, Processes

Normative and legal instruments

Adoption of treaties, conventions Resolutions of international organisations (WHA, UNGA) Normative international instruments (‘soft law’), including global strategies and action plans, recommendations, guidelines

Political accountability mechanisms

Goals, targets, indicators, timelines, especially when supplemented by periodic reporting requirements (to the UNGA, WHA, etc) Partnerships between key actors, including UN agencies, governments, private funders, INGOs Accountability mechanisms used by civil society organisations (e.g., indexes, shadow reports)

Economic support and incentives

Development assistance in health: provision of direct economic and material support Funding conditionalities

Capacity-building

Coordination of training, mentoring and capacity building; sharing good practises and facilitating access to information Advocacy by champions in civil society and private sector Popular movements in civil society Media campaigns mobilising popular opinion

Less formal pathways

Intended Impact at National Level

→ Legal and normative pressure for domestic policy change Better understanding of the case for policy action, better knowledge about policy options and policy priorities → Greater political commitment and pressure on national governments to implement effective policies Improved capacity for policy action at national level

→ Material resources for programs and initiatives Economic pressure for policy actions at national level → Greater capacity for implementation of recommended policies and law

→ Normative pressure for global and national policy change

Children’s and Adolescents’ Health (2016-2030)’ (WHO 2017b), and the ‘WHO Global Action Plan on Physical Activity 2018–2030’ (WHO 2018b). Although not focused specifically on NCDs, the reports of the special rapporteurs on the right to health and the right to food reflect additional sources of normative guidance that are conceptually aligned although poorly integrated with WHO guidance. The historical roots of the right to food (found in article 11 of the International Covenant on Economic, Social and Cultural Rights, ICESCR) lie in hunger alleviation, through access to ‘sufficient, nutritionally adequate and safe’ food (ECOSOC 1999). However, the Special Rapporteur on the Right to Food, appointed by the Human Rights Council under the special procedures mandate, has emphasised the need for an enabling environment that

Non-Communicable Diseases   637 promotes sustainable diets and addresses all dimensions of malnutrition: inadequate calories, micronutrient deficiencies, and overconsumption of nutrient-poor food, leading to obesity (de Schutter 2014a). In particular, this requires strengthening of local food systems and a new framework for trade and investment in agriculture, together with national laws and policies for better nutrition (de Schutter 2014b). These broader implications of the right to food are reflected in the emerging right to ‘food and nutrition security’ (de Schutter 2014a; Ayala and Meier 2017). The right to health is also found in the ICESCR (article 12) and in a range of other global and regional human rights instruments (WHO 2017c). The special rapporteur on the right to health has emphasised the links between unhealthy foods and NCDs, urging greater transparency in the negotiation of trade and investment agreements and arguing that the duty imposed on states to protect the enjoyment of the right requires them to regulate food industry practises that encourage unhealthy diets and harm health (Grover 2014).

Political Accountability Mechanisms The convening role of deliberative bodies such as the WHA and UN General Assembly creates a range of opportunities for exerting political pressure and seeking to hold countries to account for their policies and actions. The drafting and adoption of resolutions, as well as the process of agenda-setting and prioritising of issues for open discussion, may exert political pressure on countries. Global targets and reporting processes play an important role, as discussed in this chapter. In some circumstances, civil society organisations may exert political pressure through participation in global processes. For example, in the case of UNAIDS, civil society organisations may contest ‘official’ country statements and file shadow reports in circumstances where they were not adequately consulted during the process of preparing national reports (UNAIDS 2017). Since the high-level UN meeting in 2011, the most substantial achievement of the WHA and UN General Assembly in fostering greater political accountability has been the adoption of global goals and targets and creation of global reporting mechanisms. Three distinct processes are distinguished here, reflecting the migration of NCDs as an issue of concern into the wider UN system. First, in 2012 WHA adopted an overall target of a 25 percent reduction, by 2025, in premature mortality from CVD, cancer, diabetes, and chronic respiratory disease. The following year it adopted eight additional voluntary goals addressing specific risk factors (see table 32.3). These nine global goals, together with twenty-five indicators, make up WHO’s global monitoring framework for prevention and control of NCDs (WHO 2013a, appendix 2). Second, monitoring and institutional frameworks have emerged to support the UN General Assembly’s involvement in NCDs. At the high-level meeting of the UN General Assembly in 2014, heads of state agreed to a number of time-bound commitments. Summarized in table  32.3, these include the obligation, by 2015, to consider setting national targets and process indicators for 2025, as well as multisectoral policies to

638   Roger Magnusson Table 32.3  Global Targets for Reductions in NCD Risk Factors Comprehensive global monitoring framework, including 9 voluntary global targets for prevention and control of NCDs (WHO)

Overall target: By 2025, a 25% relative reduction in mortality from cardiovascular disease, cancer, diabetes, and chronic respiratory diseases in persons aged 30–70. Eight supporting targets: 10% relative reduction in harmful use of alcohol; 10% relative reduction in prevalence of physical inactivity; 30% relative reduction in mean average population salt intake; 30% relative reduction in prevalence of tobacco use (persons 15 + years); 25% relative reduction in raised blood pressure; 0% increase in diabetes and obesity; 50% coverage for drug therapy and counselling for those at risk for cardiovascular disease; and 80% coverage of affordable technologies and essential medicines for treating NCDs in both public and private facilities.

Sustainable Development Goals: Target 3.4 (UN General Assembly) Time-bound commitments made by heads of state at the 2014 High-Level Meeting of the UN General Assembly on NCDs

By 2030, reduce by one-third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being. Four time-bound targets: By 2015, consider setting national targets for 2025 and process indicators based on national situations, taking into account the 9 voluntary global targets for NCDs (adopted by the World Health Assembly in 2013). By 2015, consider developing or strengthening national multisectoral policies and plans to achieve the national targets by 2025, taking into account WHO’s global action plan on prevention and control of NCDs. By 2016, as appropriate, reduce risk factors for NCDs and underlying social determinants through the implementation of interventions and policy options to create health-promoting environments, building on the guidance in appendix 3 of the global action plan (menu of policy options and cost-effective interventions). By 2016, as appropriate, strengthen and orient health systems to address the prevention and control of NCDs and underlying social determinants through people-centred primary healthcare and universal coverage, building on the guidance in appendix 3 of the global action plan.

achieve them (UNGA 2014). By 2015, 138 countries had shown ‘very poor’ or no progress in meeting these commitments (WHO 2017a). WHO developed a separate monitoring framework, comprising ten indicators, for the purposes of its report to the UN General Assembly in 2017, ahead of the 2018 high-level meeting on progress achieved under the UNGA process (WHO 2015b). These indicators track countries’ progress in setting national targets, developing a multisectoral

Non-Communicable Diseases   639 national action plan, and implementing a range of WHO-recommended policies relating to prevention and treatment. The adoption of the sustainable development goals (SDGs) by the UN General Assembly in September 2015 represents a third set of targets and reporting processes for NCDs. The SDGs comprise aspirational targets for global development for all countries for the period 2015–2030, irrespective of income level. The SDGs contain an ambitious target for NCDs: ‘By 2030, reduce by one third premature mortality from non-­communicable diseases through prevention and treatment and promote mental health and wellbeing’ (UNGA 2015). The three reporting systems have different timelines, and in the case of the SDGs, extend well beyond NCDs. In addition to targets and monitoring systems, the development of governance structures is a vital part of global efforts to strengthen political accountability for action on NCDs. Governance mechanisms help to institutionalise NCDs within the work programs of global institutions and to coordinate strategic leadership, which is vital when leadership is diffused or shared. In 2013, on the recommendation of the UN General Assembly, the UN Social and Economic Council (ECOSOC) established the United Nations Interagency Task Force on NCDs (UNIATF), with the role of coordinating and strengthening the efforts of UN and intergovernmental agencies on NCDs (ECOSOC 2013; WHO 2017d). UNIATF is led by WHO. Its terms of reference set out a division of responsibilities between UN and other entities, with the goal of strengthening national, regional, and global action plans for prevention and control of NCDs, including through exchange of information about best practises in health promotion, legislation, regulation, and health systems strengthening (WHO 2015c). Separate from UNIATF is the Global Coordinating Mechanism for Noncommunicable Diseases (GCM/NCD), established in 2013 by WHO (WHO 2013b). GCM/NCD provides a platform for collaboration amongst WHO member states, UN agencies, other intergovernmental partners, and nonstate actors, including civil society organisations and academic and select private sector entities. Its goal is to enhance collaboration across sectors at national, regional, and global levels, whilst safeguarding WHO and public health processes from conflicts of interest (WHO 2013b, 2014). Working groups have been established in five areas, in accordance with the GCM/NCDs workplans. GCM/ NCD also hosts dialogues, as well as an expanding set of online communities of practise, including in NCDs and health literacy; NCDs, health, and law; and multisectoral action on NCDs (WHO 2017e). The development of regional counterparts to the GCM/NCD and to UNIATF provides the opportunity to further institutionalise NCDs within regional development organisations (such as the Pacific Community and the African Union) and to strengthen links with national aid programmes. A final achievement worth mentioning is the high-level meetings of the UN General Assembly themselves, held in 2011, 2014, 2018 with a fourth scheduled for 2025. All three meetings have provided a focus for advocacy, an opportunity for expressions of political commitment at the highest level, and political declarations that re-state the challenge, and set out commitments for the future (WHO 2018c).

640   Roger Magnusson

Economic and Material Support for Policy Implementation Global targets and governance structures play a role in raising the political priority of NCDs in countries; normative instruments identify cost-effective policies that governments can implement. Economic support and technical assistance are the critical link between knowledge and action. In low-income countries, they provide the material and human resources that make actions at the country level possible. But here the narrative breaks down. Despite knowledge about the health impacts of NCDs, donors have been unwilling to direct substantial resources to this area. An important lesson from HIV—with which NCDs share many similarities—is that progress is more likely when countries integrate policies for both prevention and treatment, whilst also addressing the social impacts of illness, including discrimination against people with diabetes and other NCDs (Magnusson and Patterson 2014). Experience with HIV suggests that the availability of treatment, including secondary prevention medications for major NCDs like coronary heart disease, stroke, and diabetes, will call attention to the importance of prevention. This is partly because the lifestyle changes that are required to reduce risk factors, or to prevent disease progression, benefit from peer education and personal testimony by those already affected. In the case of secondary prevention for the diseases mentioned, treatment literally is prevention, whilst conversely, population-wide prevention policies can reduce the economic burden of treatment costs (e.g., smoke-free laws may lead to substantial, rapid declines in medical facility admissions for heart attacks and asthma; Faber et al. 2017; Capewell and O’Flaherty 2011; Been et al. 2014; Sims et al. 2010). The fact that lack of investment in prevention will increase the costs of treatment, whilst lack of investment in treatment may undermine the effectiveness of prevention, suggests that careful thought should be given to the mix of policies and programs that are implemented with the scarce resources that are available. Bonita and colleagues argue that countries with the least resources should focus on developing their human, financial, and regulatory capacity in order to implement a limited set of cost-effective interventions in a step-wise manner: tobacco control measures, reduction in population salt intake in order to lower blood pressure, and multi-drug treatment for those who have had or are at high risk of having a heart attack or stroke (Bonita et al. 2013). If the future of NCDs in low-resource countries depends largely on ‘self-help’, then capacity building and the development of human resources will be crucial. Many of the priority, cost-effective interventions recommended by WHO are regulatory in character, requiring fiscal policies by governments (e.g., raising taxes), and implementation of legislation, regulations, executive orders, or decrees (Magnusson and Patterson 2014; Gostin et al. 2017). One measure of success in raising the political profile of NCDs through global governance mechanisms such as UNIATF and GCM/NCD will be greater demand for technical assistance in implementing cost-effective national policies for both treatment and prevention. However, WHO’s lack of control over three-quarters of its total budget renders it ‘miserably under-resourced’ to respond to country requests for assistance (Mendis 2016). Encouraging funders to grasp the vision required to

Non-Communicable Diseases   641 develop a next-generation network of practitioners with expertise in cost-effective ‘best buys’, including regulatory and legal measures, remains an important challenge for this generation (Ruchman, Kishore, Singh 2016).

Contesting Policy: Industry Fights Back Any review of NCDs and global health politics must acknowledge the reality of ideological and industry-led resistance to many of the policies that could most help to ease the burden. A growing literature documents the strategies that the tobacco, alcohol, food, and sugary drinks industries use to resist the implementation of policies that could threaten their economic interests. They include formal submissions to governments, direct lobbying of government ministers and bureaucrats, corporate social responsibility (CSR) campaigns, philanthropy, funding and control of research, disinformation, advertising, the development of (weak/permissive) voluntary codes and standards, and industry-funded and industry-friendly front groups (Malone 2010; Zeigler 2010; Wiist 2011; Mindell et al. 2012; Jernigan 2012; Dorfman et al. 2012; Yanamadala et al. 2012; Moodie et al. 2013; Savell, Fooks, and Gilmore 2015; Mialon, Swinburn, Wate, et al. 2016; Mialon, Swinburn, Allender, et al. 2016; Wilson and Roberts 2012; Martino et al. 2017). At the global level, political activity by the tobacco, alcohol, food, and sugary drinks industries poses risks to the integrity of the technical and normative guidance produced by WHO and to the collective willingness of countries to fulfill their commitments under global accountability mechanisms. For example, in 2003 WHO published a technical report on diet, nutrition, and the prevention of NCDs that included a recommendation to limit free sugar intake to no more than 10 percent of daily energy intake (WHO 2003b). In response, the US Department of Health and Human Services produced a detailed critique that an article in the New York Times described as ‘blatant pandering to American food companies that produce much of the world’s high-calorie, high-profit sodas and snacks’ (Brownell and Nestle 2004). Before and after the publication of this report, the sugar industry and its allies lobbied the US Secretary of Health and Human Services to withdraw US funding from WHO (Norum 2004). A concerted attempt to weaken WHO’s global strategy on diet, physical activity, and health followed (Norum 2004). Although adopted by WHA in 2004, this strategy document omitted any reference to the 2003 technical report and its proposed limit on free sugars (Norum 2004). In 2015 WHO reiterated its recommendation on free sugars, citing links between free sugar intake, obesity, and dental caries. This report included a conditional recommendation to reduce free sugar intake below 5 percent of total energy intake (WHO 2015a). The efforts of the sugar lobby illustrate the importance of protecting the development of national policies, as well as the integrity of core global health functions, including evaluating evidence, and developing guidance, from vested economic interests (Buse, Tanaka, and Hawkes 2017). This challenge persists, not only with food and nutrition (WHO 2016b), but also with tobacco control, an area where conflicts of interest might be considered most apparent (WHO 2008a).

642   Roger Magnusson For example, in 2017 the Foundation for a Smoke-free World was launched, with a promise of funding of US$80 million per year for twelve years from tobacco giant Philip Morris International (PMI). The aims of the foundation are to ‘advance smoking cessation and harm-reduction science and technology’ (Foundation for a Smoke-free World 2017). Although ostensibly independent, the activities of the foundation appear to depend on discretionary annual or periodic funding renewal by a tobacco multinational. Although the foundation does not yet have a record of advocacy or research, PMI would clearly benefit from third-party advocacy to remove the ban on e-cigarettes and heated tobacco products in jurisdictions where they are prohibited (such as Australia) and to reverse the trend towards applying smoke-free laws to both combustible and non-combustible products seen in jurisdictions including California and New York. California, which has raised the minimum purchasing age for cigarettes to twenty-one years, applies the same requirement to e-cigarettes (California Senate Bill No. 5, 2015–2016). Whatever its activities, it is difficult to see how the Foundation can avoid performing a valuable public relations function for its economic parent. That function is damaging to global tobacco control efforts, since for all its talk about ‘smoke-free futures’ (Horne 2017), PMI continues to behave as a regular tobacco multinational, exploiting the opportunities provided by jurisdictions tobacco control laws and enforcement capacity are weak (Kalra et al. 2017). This leads to a final point about the role of industry in pushing back against policies and accountability mechanisms that put profits at risk. Private regulatory instruments— including voluntary pledges, codes, and guidelines—are a familiar response to NCDs, ostensibly governing industry conduct in areas such as alcohol advertising, food labelling, and food reformulation. In Western democracies, scholars have argued that globalisation and the impact of neo-liberal policies have had a destabilising influence on the capacity and/or disposition of the state to regulate. This is seen in the dismantling of welfarist policies and in a retreat from—or in the privatisation of—what might once have been considered state functions (Clarke 2004). Regulatory scholars have referred to the current era as one of ‘regulatory capitalism’: its key features include growing corporatisation and privatisation; the diffusion of regulatory power amongst private, state, and nonstate actors; and the emergence of new, hybrid regulatory instruments (LeviFaur 2005; Black 2001). This subcontracting out of regulatory functions by the state to industry has obvious implications for the diffusion of NCD risks and requires a broader framework for understanding how governments and corporate actors can be held to account (Swinburn et al. 2015; Stevenson 2015).

Opportunities for Accelerating Progress in the Global Response to NCDs NCDs are now a visible part of the agenda for WHO and the UN General Assembly, and UN agencies are getting involved through shared UN structures such as UNIATF. On the other hand, it is far from clear that WHO or UN agencies have the political clout

Non-Communicable Diseases   643 to meaningfully influence global policies on trade or agriculture, or to achieve greater accountability by multinational corporations (Buse, Tanaka, and Hawkes 2017). As far as DAH is concerned, resources have not followed the evidence, whilst at the national level, the implementation of recommended policies is obstructed by the food, alcohol, processed food, and sugary drinks industries and their allies.

Reform of Global Governance Structures Some scholars have argued that only new, legally binding instruments, such as framework conventions on global health (Gostin et al. 2013), alcohol control (Sridhar 2012), and obesity and healthy diets (World Obesity 2014), can address root causes and create the necessary momentum. Others have argued for reform of the political structures for health governance. Mackey and Liang (2013) proposed a high-level panel on global health, to be created by UN General Assembly resolution and chaired by WHO, with a mixed membership made up of UN agencies, funding agencies, NGOs, industry entities, and states. Supported by a technical group, the panel’s roles would include resource mobilisation and global agenda setting through recommendations to UN agencies, including WHO itself. Nishtar (2017) proposed a multistake holder NCD-focused body to engage with the private sector and encourage innovative funding mechanisms.

Using Existing Structures More Effectively Even in the absence of new conventions or fundamental institutional changes, opportunities may exist to make better use of existing governance structures. For example, human rights scholars argue that global actors, including WHO and UN entities, should make greater use of human rights instruments and the existing UN human rights system. This could include framing policy actions for improving diets and nutrition in terms of the human right to health and to food and strengthening global monitoring and enforcement mechanisms (Ayala and Meier 2017). Although the right to food and nutrition is missing from the SDGs (Pol and Schuftan 2016), human rights are an important part of the political conversation in many countries, especially those where health-related rights are recognised in national constitutions (Heymann et al. 2013). The Committee on Economic, Social and Cultural Rights (CESCR) within the UN Economic and Social Council could assist this process by updating and revising the ‘General Comment on the Right to Adequate Food’ (ECOSOC 1999) in order to clarify its full conceptual scope. Scholars have also argued that the human rights system could require greater accountability from countries regarding implementing their obligations under the WHO FCTC. For example, Cabrera and Gostin (2011) argue that the FCTC functions as a standard for gauging whether states are discharging their obligations to respect, protect and fulfill the right to health, and that the Committee on Economic, Social and Cultural Rights (CESCR), as the treaty body monitoring the implementation of the right to health, should

644   Roger Magnusson take the opportunity to recognise this relationship more explicitly, especially in periodic country reviews. Similarly, Toebes and colleagues argue that the individual complaint procedure in the Convention on the Rights of the Child provides a potential means of redress against countries’ failure to consider the best interests of children in setting domestic tobacco control laws, whilst also supporting efforts to raise tobacco taxes, implement minimum purchasing age restrictions, and other controls (Toebes et al. 2018).

Public-Private Partnerships A very different prescription for advancing progress on NCDs comes from scholars who argue that governments should engage in smart partnerships with industry, in order to make better use of their market power and technological know-how. There is a credible consensus, reflected in article 5.3 of the WHO FCTC and in the Guidelines for Implementation of Article 5.3, that there is an ‘irreconcilable conflict between the tobacco industry’s interests and public health interests’ (WHO 2008a). The tobacco industry is not a public health stakeholder (Novotny 2013). The guidelines on article 5.3 recommend that parties to the FCTC interact with the tobacco industry only when strictly necessary in order to regulate it, reject partnerships and non-binding agreements with the tobacco industry, and not accept voluntary codes or instruments drafted by the tobacco industry as a substitute for legally enforceable tobacco control measures (WHO 2008a). However, this consensus is less evident with alcohol and is particularly controversial with ‘big food’. There is ongoing debate in the literature about whether and under what conditions the food industry might be an appropriate partner in reducing NCD risk factors (Yach et al. 2010; Yach 2016; Stuckler and Nestle 2012; Gilmore, Savell, and Collin 2011; Brownell 2012; Kraak et al. 2011; Johnston and Finegood 2015; Bryden et al. 2013; Stevenson 2015). Opportunities clearly exist for ‘big food’ to voluntarily reduce diet-related harm through product reformulation, portion resizing, and ceasing the shameless promotion of unhealthy food to children (Ng, Slining, and Popkin 2014). However, the ‘opportunity costs’ of prioritising partnerships over regulation are less visible. Could greater progress have been achieved if governments had not delegated regulatory control to industry or given implicit concessions to industry in return for some degree of industry cooperation or forbearance? Although debate often reflects a contest between the merits of voluntarism (self-­ regulatory codes, public-private partnerships) and regulation (mandatory standards, legislation), the deeper issue is about results, secured by robust accountability mechanisms for evaluating performance (Sharma, Teret, and Brownell 2010; Swinburn et al. 2015). This is one reason the adoption of national goals for improvements in risk factors for NCDs is so important (Magnusson 2017). Where results are not achieved, governments need to be willing to scale up their level of involvement and to consider regulation (Reeve and Magnusson 2015). For example, clear targets and timeframes, independent monitoring, media pressure, and sustained political pressure on industry were all

Non-Communicable Diseases   645 central to the relative success of the UK government’s voluntary approach to reducing salt levels in processed food, begun in 2003 (He and MacGregor 2015).

Progress in the Absence of Fundamental Reform Current challenges for global health, including lack of global enforcement mechanisms, WHO’s increasing reliance on extra-budgetary funding, and the lack of accountability of health-harming industries, did not arise by accident. Ultimately they reflect the collective will of UN member states not to resource health adequately or to give it priority in global affairs. Although routinely castigated, WHO deserves credit for what has been achieved: a set of voluntary global targets for measuring progress, an evolving UN mechanism for global monitoring, structures for coordinating cross-sectoral action with UN agencies as well as with nonstate actors, and the development of a significant body of normative guidance. An important question arises: Even in the absence of fundamental reform, are there opportunities for strengthening global action on NCDs? The answer is yes. First, at the global level, the NCD silo must be broken down. Actions to strengthen prevention and improve treatment of NCDs must be identified and integrated within national strategies for poverty reduction, advancing universal health coverage, and advancing towards the SDGs. Areas of overlap between NCDs and universal health coverage include improving care models to promote continuity of care, improving affordable access to essential medicines, developing the NCD workforce, supporting technologies and strategies for better self-care, and ‘provider payment systems that reward prevention and the maintenance of wellness’ (Cassels 2015). Action on climate change could also benefit significantly from NCD-informed policies; a growing literature addresses the opportunities and synergies (Watts et al. 2017; Friel et al. 2011; Lowe 2014; Carlsson-Kanyama and González 2009; Wilson and Edwards 2008). Whilst better results depend on integrating action on NCDs through a wide variety of global programmes, ironically, the political priority that NCDs need to achieve in order to do this successfully will almost certainly require a higher degree of NCD exceptionalism than exists at present. Whilst this does not imply a UNAIDS style of body, high-level institutional machinery—something more exciting than the UNIATF—is likely required to drive work forward between high-level UN meetings. Second, decisive global action on NCDs will not happen until there is greater demand for action by countries, pushed in turn by civil society. This requires emotion, an ingredient conspicuously missing from the NCD narrative. As a global movement, NCD activism needs a vision for health justice, not just technical facts. It needs moments of outrage. Capturing them requires civil society organisations and academia to document evidence of predatory corporate practises and other injustices and their impact on children, women, vulnerable minorities, and health inequalities. The challenge is to ‘transform data into moral arguments’ (Smith, Buse, and Gordon 2016), to ‘give the people who suffer most a face and a voice’ (Chan 2017).

646   Roger Magnusson A welcome starting point is the Advocacy Agenda of People Living with NCDs, developed by the NCD Alliance following a global consultation process (NCD Alliance 2017). Key messages in the agenda include the call for an ‘urgent and fundamental shift in the NCD response’ to ensure ‘meaningful involvement’ of people living with NCDs in programme development, implementation, policymaking, and accountability processes at national and global levels. Human rights and social justice lie at the core of the ‘priority asks’ outlined in this document. The Advocacy Agenda calls for high-quality care for those with NCDs; the right to be treated with respect by healthcare providers; actions to address discrimination, stigma, myths, and fears about NCDs; and improved accessibility of public transport, work, and public spaces for those with disabilities. Third, countries and regions may find it helpful to appoint rapporteurs on NCDs: respected, self-driven champions with the capacity to capture media attention, to motivate and strengthen civil society networks, to challenge and ‘call out’ business, and to lead a national conversation towards greater accountability. These roles will not be easy, but the concepts and language of human rights are an important ally; they frame action on NCDs as an entitlement, an obligation of governments: an issue of health justice (IDLO 2015). Global and national action on NCDs, no less than universal health coverage, must be ‘struggled for and won by social movements’, since it is unlikely to be ‘spontaneously bestowed by governments’ (WHO 2008b, 25). Packages of accountability measures must be tailored to each issue, and one size will not fit all (Swinburn et al. 2015). Access to NCD medicines is not a bad starting point. For example, access to affordable blood-pressure-lowering medicines remains dire in low- and lower-middle-income countries. Attaei and colleagues found that in their study of drug availability in 626 communities, only 13 percent of community pharmacies had all four blood-pressure lowering drugs in stock, and 75 percent of households in low-income countries were unable to afford the cost of the two lowest cost blood-pressure-lowering medicines, plus the lowest cost statin (Attaei et al. 2017). NCDs are a new front for activism about access to medicines; people ought not to miss out on the medicines needed to keep them alive or to risk catastrophic expenditure securing access. Fourth, smaller countries and economies, such as island states in the Pacific, Caribbean and Indian Oceans and some African countries, could consider strategic coordination through a regional approach. This could extend to the development of shared, regional human resources and development of common policies and legislation, including in the areas of trade and agriculture (Magnusson and Patterson 2015; Magnusson 2017). Fifth, many of the evidence-based ‘best buys’ recommended by WHO (2017a) are not expensive and could be implemented in a step-wise fashion where appropriate national plans, cross-sectoral structures, and capacity are in place. The investment needed to develop national or regional capacity in robust, regulatory measures for tobacco, alcohol, and healthy diet is modest (Bonita et al. 2013; Colagiuri et al. 2015). Targeted investment in these areas by development partners makes sense and could be made sustainable by revenue-raising policies, including raising taxes on tobacco, alcohol, and sugary drinks.

Non-Communicable Diseases   647 Sixth, change is coming. Mexico’s experience with a sugary drinks tax (Cochero et al. 2017), Australia’s experience with tobacco plain packaging (WHO 2016c), South Africa’s experience setting maximum salt levels for thirteen food categories (Republic of South Africa, Minister of Health 2016), and Denmark’s limit on industrially produced trans fats (Downs, Thow, and Leeder 2013) are all examples of novel measures that are spreading internationally. When national governments are unable to act, opportunities may exist for regional, city, and local governments, as illustrated by Michael Bloomberg’s pioneering initiatives as Mayor of New York City (Gostin 2013). A final issue worth returning to is the misleading nature of the term non-communicable diseases itself. ‘Prevention and control of NCDs’ has become recognised code for work relating to four major diseases (CVD, cancer, diabetes, and chronic respiratory diseases) and their societal, behavioural, and physiological risk factors. Allen and Feigl (2017) argue that a ‘longwinded non-definition’ is unlikely to attract funding and harms prevention efforts by conveying the message that the causes of NCDs are ‘individual rather than societal’. Far from holding the tobacco, alcohol, food, and beverages industries to account for shameless profiteering at the expense of global health, the very term suggests that individuals with NCDs have ‘done it to themselves’. Unfortunately, an alternative term that would capture the complex global causes of NCDs and their risk factors and resonate with funders, patients, and politicians has proved elusive. The message to be conveyed is that NCDs are chronic and often insidious conditions whose prevalence reflects trends in underlying risk factor patterns, as mediated through commercial, physical, policy, and social environments (Ezzati and Riboli 2013). Ackland and colleagues advocate the term transmissible chronic diseases (Ackland, Choi, and Puska 2003).

Conclusion NCDs are a group of diseases with interrelated risk factors underpinned by expanding global markets for unhealthy products. They reflect a darker side of globalisation. In the absence of the global outpouring of emotion that characterised the response to HIV/ AIDS, the global response to NCDs has tended to be technical. WHO has advocated cost-effective policies and established monitoring mechanisms. However, resources to support implementation in low-income countries, and shared learning, have not materialised. Since 2011, the locus of governance of NCDs has moved beyond WHO towards the wider UN system. NCDs now have a place within the UN development agenda, although WHO’s coordinating role remains central. Whilst there is no single silver bullet for NCDs, that does not mean there are no bullets at all. At the global level, universal health coverage and the SDGs provide conceptual frameworks and reporting structures for engaging governments and measuring progress. At the national level, the priority is to make NCD risk factors and diseases

648   Roger Magnusson ­ utcome measures for interventions across a range of sectors. Success will be reflected by o the insertion of action on NCDs within national development plans (Cassels 2015). For smaller countries, regional action could accelerate the rate of change. Without action, national economies will underperform, dependency rates will rise, and life expectancies may literally shrink. Taking action brings its own risks. Addressing conflicts of interest will be a constant challenge at all levels, as profitable industries seek to nurture cozy relationships with politicians, talking up the contribution of business without addressing fundamentals. For example, if the world’s largest brewer can convince governments it is a credible partner for advancing global efforts to reduce harmful alcohol use (SDG target 3.5) using its ‘Global Smart Drinking Goals’ as a framework for action (Taylor, Nalamada, and Perez 2016, 43–44), how likely is it, really, that governments will fully implement WHO’s global strategy on harmful alcohol use (WHO 2010c)?

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chapter 33

The Politics of Gl oba l Tobacco Con trol Kelley Lee

There is arguably no anomaly so enduring in public health as the long-standing battle for effective tobacco control. It is frequently noted that if cigarettes were invented today, tobacco companies would not be legally permitted to sell them as a ‘fast-moving consumer good’, given their lethal nature (Tiffin 2015). Prematurely killing half of regular smokers, tobacco use has been the leading cause of preventable deaths worldwide for decades. In 2018 tobacco use caused around seven million deaths globally, a sharp rise from three million deaths in 1994 (Peto, Lopez et al.  1996). Cumulatively, one hundred million deaths were caused by tobacco use over the twentieth century; this is expected to rise to one billion deaths over the twenty-first century (WHO 2008). Efforts to control the production and consumption of this ‘noxious weed’, as King James 1 described tobacco in 1604, began from its introduction into Europe from the Americas during the fifteenth century. Over the next four hundred years, tobacco use remained a controversial habit for moral, economic, and cultural reasons. Historians document tobacco as being central to colonisation from the sixteenth century, the slave trade from the seventeenth century, creation of the corporation during the nineteenth century, and the rise of mass consumerism during the twentieth century (Gately 2001; Brandt 2007). Scientific evidence of the adverse health effects of tobacco use began to accumulate during the nineteenth century, but it was an epidemiological study by Doll and Hill (1954) that definitively linked smoking to lung cancer. An initial decline in smoking rates prompted by this research was reversed by the industry’s introduction of ‘filtered’ cigarettes to allay health concerns. The 1964 US Surgeon General’s Report on Smoking and Health (US Surgeon General, 1964) confirming the health risks proved a more significant turning

662   Kelley Lee point (Cummings and Proctor 2014). A mountain of scientific evidence has since been published on the adverse first-hand (direct), second-hand, and even third-hand health effects of tobacco use. And yet despite irrefutable evidence, tobacco use has continued apace and may even still be rising worldwide. This chapter argues that any explanation for the persistent and widespread use of tobacco despite abundant scientific evidence of its deadly effects must locate politics at the heart of the story. On the one hand, tobacco is now among the most regulated of consumer products in most countries. On the other hand, it has taken more than sixty years since Doll and Hill’s study to reach what remains an uneven patchwork of regulation across jurisdictions. Tobacco products continue to be sold, legally and illegally, in vast quantities worldwide. Cigarette retail sales in 2017 totalled US$700 billion (Campaign for Tobacco Free Kids  2018), earning downturn-busting dividends for shareholders of leading transnational tobacco companies (TTCs) of US$19 billion (Davies 2017). The hard-fought politics of ‘regulation, taxes, and litigation against tobacco companies’ (Studlar 2002, 17) across a diverse range of national contexts is well-documented (Studlar and Cairney 2014; Cairney and Yamazaki 2017). There are illustrative case studies and comparative analyses of why, for example, ‘governments take particular actions’ and why ‘some levels of government have been more restrictive in tobacco control in each country’ (Studlar 2002, 17). Building on this important work, the purpose of this chapter is to extend analyses of the politics of tobacco control to the global level. How have political conflicts between a highly profitable industry and public health advocates played out above the level of the state in recent decades? What strategies have they pursued, and to what effect, and what does this tell us about the contemporary nature of global health politics? To answer these questions, this chapter is organised into three broad periods. First, the shift by leading tobacco companies from the 1960s, from largely domestic to regional and global firms, is briefly described. This shift, and the consequent rise in tobacco-related disease and death within targeted markets from the 1980s, prompted new concerns within the public health community. Second, an analysis of the politics surrounding the negotiation of the Framework Convention on Tobacco Control (FCTC) from the 1990s to mid-2000s is presented. The emergence of a global tobacco pandemic prompted public health advocates to seek to shift tobacco control from a long-neglected issue focused on changing individual behaviour to a high-priority challenge requiring collective action through global health governance (GHG). Third, the shifting political strategies by industry and public health advocates since the FCTC came into force in 2005 are set out. Far from ending political battles, adoption of the treaty shifted the terrain of con­ test­ation back to signatory states. Moreover, public criticism and new measures under FCTC Article 5.3 to prevent industry interference in health policy led the industry to rehabilitate its public reputation by engaging in research and policy on the illicit trade and harm reduction.

Politics of Global Tobacco Control   663

Globalisation of the Tobacco Industry: The Emergence of a Commercially Driven Pandemic The adoption of stronger tobacco control policies in the United States following the US Surgeon General’s (1964) report marked an important turning point in public attitudes towards smoking, prompted by a tipping point in the volume of scientific evidence about the harmful health effects of tobacco use. The decline in smoking rates that followed, despite industry denials of the evidence, prompted leading cigarette manufacturers to expand their markets beyond the United States, initially focused on Latin America. As Shepherd (1985) describes, new markets were essential to compensate for declining sales in ‘traditional markets’. Whilst leading cigarette manufacturers were already operating worldwide beginning in the early twentieth century, the strategy was to grow these foreign markets as a much larger part of their business. By the 1980s the spread of neoliberalism and economic globalisation enabled a second wave of expansion. Pressured by the US Trade Representative, who faced ‘intensive lobbying efforts’ (Webb 1988) from the US Cigarette Export Association, several Asian countries were forced to open their cigarette markets (Chantornvong and McCargo 2001; MacKenzie, Lee, and LeGresley 2016). The ending of the Cold War in the early 1990s and the collapse of the Soviet Union brought further expansion into Eastern Europe (Gilmore and McKee 2004). This was followed by fierce competition among leading tobacco companies to grow larger by gaining market access and share in the Middle East and Africa (Nakkash and Lee 2008). As Philip Morris International (PMI)’s president described to the company’s board of directors: 1990 is the beginning of what will undoubtedly be a decade of great change for our business. The political and economic restructuring of Eastern Europe, the realisation of a Single Market in the EEC, the move towards free market economies in Latin America, and the lowering of trade barriers throughout Asia, are major events which are reshaping the world we do business in. These developments are providing very substantial opportunities in the tobacco industry and we are moving quickly to exploit them.  (Buzzi 1990)

In the late 1990s mergers and acquisitions concentrated ownership of cigarette manufacturing (excluding China) in the hands of a small number of TTCs led by PMI, British American Tobacco (BAT), Japan Tobacco International (JTI), and Imperial Tobacco. The expansion of TTCs into ‘emerging markets’ raised alarm bells among public health advocates. Historically, international cooperation on tobacco control was given relatively low priority. At the first World Conference on Tobacco and Health (later

664   Kelley Lee Tobacco or Health) in 1967, national delegations focused on reviewing scientific evidence on the harmful health effects of smoking and on sharing information on tobacco control policies. In 1970 the WHO director-general presented a report to the World Health Assembly (WHA) on ‘the limitation of smoking’, calling, inter alia, for member states to end cigarette advertising and promotion. This was accompanied by the adoption of a resolution on the ‘health consequences of smoking’, which called on member states to refrain from smoking at WHA meetings, discourage smoking among young people, and urge the Food and Agriculture Organization (FAO) to study crop substitution for tobacco-growing countries. The limited scope of these initial international efforts was mirrored in the small size, limited budget, and low status of WHO’s Tobacco and Health Unit, formed in 1990. As former staff member Neil Collishaw describes, ‘I was . . . involved in documenting the scale of the tobacco epidemic, and . . . preparing publications . . . .We did all this on a shoestring budget’ (as quoted in Boucher 2000). Low resourcing was due in large part to the policy of zero real growth in WHO’s regular (assessed) budget, adopted in 1981 with the support of the Geneva Group (largest financial contributors to the United Nations system). The group included the US government, which considered adoption of the Model List of Essential Medicines in 1977 and the International Code of Breastmilk Substitutes in 1982 a ‘politicisation’ of WHO’s mandate (Lee 2008). This began a shift towards funding a greater proportion of WHO’s total budget by extra-budgetary (voluntary) contributions, which donors could earmark for specific purposes. As Vaughan et al. (1996) report, donors preferred to fund such areas as communicable disease outbreaks and emergency response, whilst other areas including chronic health conditions received limited donor support. Moreover, the dominant public health narrative for tobacco control was ‘lifestyle diseases’, attributable to the ‘risky’ behavioural choices of individuals. This apportioning of cause to individual behaviour in turn cast tobacco-attributable morbidity and mortality as somehow self-inflicted. Given the dominance of this narrative, donor funding to support tobacco control remained very limited. Consequently, the Tobacco and Health Unit’s work focused on collecting data on tobacco use and its health consequences from member states. Even this purpose proved challenging given that few countries collected national data. The lack of standardised methodology also prevented collection of aggregate and comparative data to accurately measure the global scale of the problem. The limited evidence base in turn made it difficult to argue that tobacco control be given higher international priority. A Philip Morris (PM) document on ‘The Activist Movement’ described the Tobacco and Health Unit’s role as ‘[e]ssentially a “public relations” function’ and WHO’s effectiveness as limited: [I]n light of its poor funding arrangements, the WHO cannot be looked upon as the powerhouse for smoking control around the world. The monies it does have available are basically ‘seedcorn’, to provide the framework and climate through the media for the growth of smoking control strategies in the Member States.  (PM 1996)

Politics of Global Tobacco Control   665

Reframing the Issue: Arguing the Need for a Framework Convention on Tobacco Control The population health impacts of the tobacco industry expansion worldwide led to recognition within the public health community of the need for a new approach focused on mobilising political support and strengthening the evidence base as political strategy.

Mobilising Political Support for an International Legal Framework Efforts to shift policy focused on two key ideas: (a) to broaden the emphasis from changing individual behaviour to addressing the social determinants of tobacco use, including the key role of the tobacco industry; and (b) to extend policy and action from the local and national levels to the global level. A 1988 WHO report, ‘Smokeless Tobacco Control’, illustrated the tension between traditional approaches and the new challenges faced. Whilst the report expressed alarm at ‘the well financed, highly sophisticated marketing programmes that transnational tobacco manufacturers have recently initiated in order to promote smokeless tobacco worldwide’, the actions it recommended were seen as the responsibility of national governments: Countries with a history of smokeless tobacco use were urged immediately to institute aggressive regulatory and educational programmes to combat it, whilst those with no recent history of such use were urged to ban the introduction of the various products or any other new form of tobacco in order to prevent the spread of the smokeless tobacco epidemic.  (WHO 1988)

The limitations of national-level action alone were raised at the World Conference on Tobacco and Health in 1990, which excluded industry representatives for the first time. Many attendees called attention to the ‘financial and political clout’ of ‘multinationals’ in the developing world, and that they were ‘engaged in a global war’ against a ‘ruthless industry’ (Crofton 1990, 560). Growing coordination among nongovernmental or­gan­ iza­tions (NGOs), such as the international information network Global link, formed by the American Cancer Society, was encouraged. The idea of WHO creating an international legal framework to advance tobacco control was revived during this period. Drawing comparisons with the law-making efforts of the International Labour Organization, International Maritime Organization, and

666   Kelley Lee most notably, UN Environment Programme (i.e., 1992 UN Framework Convention on Climate Change), American legal scholar Allyn Taylor argued that other international organisations have at times been able to overcome member nations’ resistance and promote legal institutions effectively without becoming political battlegrounds. The comparison to other international organisations suggests that WHO’s lack of legal initiative cannot be attributed exclusively, or even predominantly, to the global political process.  (Taylor 1992)

Taylor partnered with law professor Ruth Roemer to promote the idea of an inter­ nation­al legal framework at the First All-Africa Conference on Tobacco or Health in 1993, co-chaired by Derek Yach (South African Medical Research Council) and Timothy Stamps (Zimbabwean Minister of Health). Roemer also discussed the idea with senior WHO staff and with tobacco control advocates at the American Public Health Association annual meeting the same year (Roemer, Taylor, and Lariviere 2005). As Yach (2005) recalls, the idea then began to gain wider traction: The idea would again have remained dormant, but the Canadian government, together with a group of NGOs, then raised it in 1994 at the World Conference on Tobacco or Health [WCTOH]. The Canadian government held a number of initial meetings in 1995-1996 which led to a resolution of the World Health Organization Executive Board [EB] in 1996, saying that this is something that needs to be worked on.

EB and WHA resolutions adopted in 1995 requested the director-general to report ‘on the feasibility of developing an international instrument’ (WHO 1995). A background paper commissioned from Taylor and Roemer met with resistance from some WHO officials, who supported a non-binding code or a treaty under the auspices of the UN. Nevertheless, EB and WHA resolutions adopted in 1996, championed by Jean Lariviere (Canada), Kimmo Leppo (Finland), and John Hurley (Ireland), called upon WHO to develop the FCTC. The decision to negotiate this particular type of legal instrument, which sets out principles and norms under which international action can proceed, along with procedures for negotiating more detailed arrangements (protocols) on specific issues, was a politically considered one. Based on the experience of the UN Framework Convention on Climate Change (and Kyoto Protocol), it was envisioned by WHO advisers that the main agreement would embody broad principles for international cooperation, thus minimising contentiousness and maximising adoptability by a higher number of member states. This vision of treaty-led collective action on tobacco control was substantially boosted by the election of Gro Harlem Brundtland as WHO director-general. Upon assuming office in 1998, Brundtland created the Tobacco Free Initiative (TFI) as one of two cabinet initiatives (along with Roll Back Malaria) and tasked Yach, as its inaugural director, to shepherd the FCTC process. According to Yach (2005): The most important thing was having Brundtland come in and think very deeply during her transitional period about the kind of problems that would attract

Politics of Global Tobacco Control   667 international support to the agency. . . . The FCTC was born out of the recognition that even if countries adopt the best national policies, they would still be subject to considerable cross-border advertising, marketing and other international influences. A treaty therefore was thought to be the best means of both galvanizing global support for tobacco control in general, but more specifically to address the cross-border and transnational aspects of tobacco control.

Strengthening the Evidence Base as Political Strategy With high-level WHO commitment to the FCTC achieved (WHO 1996), it was recognised that broadening political support among member states ahead of formal ne­go­ti­ ations was needed. One means of achieving this goal was to strengthen the evidence base. WHO officials began improving the quality of national-level (and aggregated regional and international) data on tobacco use and its health impacts. This was a challenging task given the long-standing neglect of the issue and varying capacity in member states to collect reliable public health data. Nevertheless, global adult and youth surveys using standardised methodologies allowed WHO to report the scale of the problem. As surveys were repeated, trend data became available for the first time, revealing which populations needed particular support. In addition to new evidence about the public health importance of the problem, WHO changed the way causal factors of tobacco use were described. For instance, Yach and Bettcher (2000) drew attention to the links between globalisation and tobacco control. Others used language reminiscent of communicable disease outbreaks, referring to the ‘global tobacco pandemic’ and to the industry as the ‘vector’ (analogous to mosquitoes and malaria) to be controlled. As well as appealing to the funding preferences of donors, new evidence and how it was framed sought to shift the prevailing view of tobacco harms as self-inflicted by weak-willed individuals to a powerful addiction created by powerful commercial interests operating on a global scale. To counter this narrative, the tobacco industry argued that tobacco control was a low priority in the developing world compared to HIV and AIDS (Smith and Lee 2016) and liver disease (Muggli et al. 2008). As described in a BAT document, ‘to maximise the impact of . . . alternative proposals for sensible regulation’, the strategy would be to claim ‘first world, Anglo-Saxon and English speaking political economies are fuelling the debate and in many cases driving the political agenda within the WHO. Most third world countries have other priorities but are not able to resist the pace, drive and political dynamics which are moving the FCTC forward’ (Vecchiet 2000, 2). Public health and industry advocates also did battle using economic data. Historically, governments have refrained from stronger tobacco control based on arguments of the sector’s economic importance. Recognising the World Bank’s influence among finance ministers, TFI worked closely with bank officials to publish new data on the net economic costs to societies from tobacco use, including healthcare costs, opportunity costs, lost productivity, and fire. New evidence of net gains through increased tobacco taxes was also generated (Jha and Chaloupka 1999). The strategic purpose of these

668   Kelley Lee economic data was to broaden support for the FCTC within governments beyond ­ministries of health. TTCs recognised the strategic importance of World Bank support for the FCTC proc­ess. A BAT (n.d.-b) document acknowledged: Brundtland has worked hard to end the rivalry which has historically existed between the WHO and other United Nations organisations. Most importantly the World Bank published . . . Curbing the Epidemic—Governments and the Economics of Tobacco Control—an analysis of tobacco use that applies innovative economic theories to conclude that smoking imposes significant net costs on the world economy. The report forms the principal economic justification for the WHO’s proposals.

In response, industry representatives reasserted familiar arguments about the economic benefits generated by the tobacco sector through employment, tax revenues, and exports (Glantz, Mamudu, and Hammond 2008). BAT (n.d.-a) focused lobbying on member states where leaf production and manufacturing were particularly important: [W]e know how the FCTC will be negotiated and we know what countries will be involved. All end markets have been alerted and key political and legal arguments have been distributed. . . . British American Tobacco’s response to date has consisted of attempting to . . . raise awareness of the FCTC’s implications among finance, trade, agriculture and employment ministers around the world.

The Tobacco Manufacturers Association (2000) reported strategic gains by working through key constituencies: The Cigarette Manufacturers’ Association of Pakistan has commented that the FCTC would reduce government revenue and take away the economic ‘life blood’ for many residents; the Andhra Pradesh Farmers’ Forum of India said elected governments, not a foreign agency, should control health measures for its citizens; and Brazil’s Tobacco Planters’ Associations said 2.1 million citizens depend on tobacco growing.

Building New Alliances in Support of Global Tobacco Control The reframing of tobacco control and the mobilisation of health and economic evidence proved essential to mobilising allies in support of or opposition to the FCTC. For WHO, overcoming the long-standing neglect of tobacco control required a broadening of support. In 1999 TFI formed the Ad Hoc Interagency Task Force on Tobacco Control, bringing together seventeen UN agencies and two organisations outside the UN system (ECOSOC 1999). The aim was to address tobacco control not only as a public health issue, but also as one supporting economic development, child welfare, environmental

Politics of Global Tobacco Control   669 sustainability, and other policy goals. WHO also recognised the need to face down political opposition from countries with major tobacco manufacturing or leaf-growing interests led by the United States. Formally, the US State Department delegated the lead negotiating role to the Department of Health and Human Services (HHS). In practise, the Bush administration gave responsibility for developing US negotiating positions to several federal agencies, including the Treasury, Trade Representative’s Office, and Departments of Commerce and Agriculture. The HHS did not fare well against these institutional heavyweights. After the deletion of ten of eleven provisions of the draft treaty as the official US position, public health physician and delegation head Thomas Novotny publicly resigned in 2001 (Kaufman 2001). A close relationship between the German government and domestic manufacturers proved a similar obstacle, especially given European Union member states’ practise of negotiating as a bloc. In Japan, despite support for the treaty from the health ministry and Japan Medical Association, the government’s stake in Japan Tobacco International (JTI) led to support for ‘a level of flexibility’ in commitments that, according to Assunta and Chapman (2006), ‘seriously weakened’ the treaty. China’s position was even more pro-industry given that the state-owned monopoly generated 9–11 percent of total public revenues (Hu 2013). Countries where growing tobacco leaf was a major source of income, such as Zimbabwe, Malawi, and Turkey, were also potential opponents of the treaty. Building support among other member states and strengthening their capacity to meaningfully participate in each of six meetings of the FCTC Intergovernmental Negotiating Body (INB) thus became critical. Regional meetings were held prior to each negotiating round, alongside engagement with regional bodies such as the Group of Latin America and Caribbean Countries and Mercosur (Mercado Común del Sur). The Southeast Asia Tobacco Control Alliance (SEATCA) emerged as a supportive coalition. African countries, led by South Africa, also coalesced into an active regional bloc. For alliance-building purposes, the appointment of diplomat Celso Nunes Amorim (Brazilian permanent ambassador to the UN) as INB chair was considered an inspired choice. As former TFI director Vera Luiza da Costa e Silva (as quoted in Lee, Chagas, and Novotny 2010) described: To be a big producer, a big exporter with a strong and influential industry, a big consumer market of tobacco products—all this pressure in the domestic market generated by allies of a powerful industry. Yet Brazil actively supported all the WHO resolutions that led to the creation of the Intergovernmental Negotiating Body. To be a country subject to all these factors and also able to implement tobacco control. We were talking at that time of being a model for other countries, mainly for developing countries to mirror [translated from Portuguese].

Moreover, as a leading emerging economy, Brazilian leadership countered industry arguments that tobacco control was only a ‘first world concern’. The appointment of a careful mix of INB vice chairs from the United States, Australia, Iran, India, South Africa, and Turkey served a purpose.

670   Kelley Lee Alliance building extended to engaging directly with a broad range of civil society organisations (CSOs)—consumer groups, women’s organisations, human rights campaigners, and others—as potential tobacco control advocates within member states (Collin, Lee, and Bissell 2002). New funding was channeled to support their involvement: Ted Turner had just created the UN Foundation and we were one of the first recipients of funding. We directed that immediately to create a cadre of NGOs and sparkplugs in the media around the world using a fairly hard-hitting campaign, one that WHO had never used before, going explicitly after a corporate sector, which WHO also had never done before.  (Yach 2005)

A critical mass of over two hundred CSOs worldwide then formed the Framework Convention Alliance (FCA), which played a critical role in lobbying member states. Recognising their political value, TFI fast-tracked officially recognised status for CSOs to enable their attendance at negotiations as observers. CSOs played a vital role in supporting smaller delegations by holding briefing sessions on key topics (e.g., illicit trade, taxation, labelling and marketing restrictions) and was a vital conduit for publicising progress on negotiations (Collin, Lee, and Bissell 2002). This strategically important role was even recognised by BAT: ‘The TFI is better organised than the WHO’s previous tobacco control initiatives. The leadership has effectively mobilised an international coalition of anti-tobacco advocates and won the pro-active support of national governments’ (BAT n.d.-b). Another important strategy was finding allies in other parts of the private sector, notably the pharmaceutical industry. As Yach (2005) describes, ‘Brundtland was willing to go to the pharmaceutical and private sectors and make the case that she was not antiprivate sector—as the tobacco industry had painted her—but she was anti-one specific sector, that is, the tobacco sector’. For this purpose, she launched a European Partnership Project with Glaxo Wellcome, Novartis, and Pharmacia & Upjohn in 1999 alongside UN secretary general Kofi Annan’s Global Compact ‘to give a human face to the global market’. The partnership’s objective was ‘reducing tobacco-related death and disease among smokers’ by supporting ‘treatment products against tobacco dependence’ (Brundtland 1999). Announcing this alliance at the World Economic Forum, ‘the foremost global partnership of business, political, intellectual and other leaders of society’ (World Economic Forum n.d.), was intended to demonstrate that WHO had powerful allies within the business community. The move was also intended to marginalise the tobacco industry within the business community with a clear message that the tobacco industry was an unacceptable face of the global market. A final group of key allies comprised legal scholars and practitioners. Taylor, Roemer, and others contributed critical analyses to support the treaty-making process (Taylor and Bodansky 1998). The FCTC process also coincided with historic litigation in the United States, which put tens of millions of pages of internal industry documents into the public domain. Lawyers from some of these cases became WHO advisers. This opened up a new field of research that revealed the political and business strategies of the industry over decades (Ciresi, Walburn, and Sutton 1999). WHO supported access

Politics of Global Tobacco Control   671 to these documents, which revealed industry efforts to undermine the World Bank’s report on ‘curbing the epidemic’ (Glantz, Mamudu, and Hammond 2008), IARC research on second-hand smoke (Ong and Glantz 2000), and the FCTC process itself (Mamudu Hammond, and Glantz 2008).

Industry Strategies to Delegitimise WHO Industry advocates recognised that the FCTC process could not be challenged using previously effective denials of health harms or economic justifications. Instead, as revealed by a WHO (2000) report, the industry focused on strategically undermining WHO from within and without: [D]ocuments show that tobacco companies sought to divert attention from the public health issues, to reduce budgets for the scientific and policy activities carried out by WHO, to pit other UN agencies against WHO, to convince developing countries that WHO’s tobacco control program was a ‘First World’ agenda carried out at the expense of the developing world, to distort the results of important scientific studies on tobacco, and to discredit WHO as an institution.

The first task was to play on the industry’s exclusion from formal negotiations on the basis of evidence of industry interference (Brundtland  2000; WHO/EMRO  2004). Along with speeches on the need for ‘genuine, constructive engagement with all stakeholders’ (Brown and Williamson  2000), the industry initiated ‘a campaign aimed at maximising opposition to the TFI proposals’ (BAT n.d.-a). One tactic was to influence the composition of selected delegations. Efforts were made to support ministries of finance, trade, and agriculture as part of the delegations of China, Japan, Malawi, Russia, Turkey, and other member states where tobacco was an important sector (Mamudu, Hammond, and Glantz 2008; Wipfli 2015). The industry appealed to economic interests by claiming the FCTC could disrupt international commerce: The international tobacco treaty proposed by WHO threatens countless potential conflicts with the work of international bodies like the World Trade Organization (WTO) and the World Customs Organization (WCO), as well as that of national, state, and local fiscal, regulatory, and judicial authorities. . . . The collapse of WTO negotiations in Seattle last December illustrated the extent to which the WTO proc­ess has already been taxed by single-issue debates over environment and labour. A multilateral tobacco agreement would produce another single issue debate and become an additional source of strain by complicating trade negotiations and ­disputes in areas as diverse as intellectual property, agricultural subsidies, and technical barriers.  (BAT 2000)

A second strategy was to undermine the perceived legitimacy of tobacco control as an appropriate subject of an international treaty, as well as WHO itself. The FCTC was initiated during a period of unprecedented criticism of the organisation, under

672   Kelley Lee Director-General Hiroshi Nakajima (Godlee  1994; Lee  2008). BAT claimed tobacco control went beyond its historical mandate: Traditionally, WHO has focused on issues of communicable diseases and public hygiene. It has not focused on the regulation of products that are deemed to have health effects. Recognizing these limitations, WHO documents on the tobacco issue attempt to characterise the voluntary consumption of legal products by adult consumers as a ‘disease’. We should be wary of permitting expansion of WHO jurisdiction based simply on WHO’s willingness to stretch of the concept of ‘disease’. (BAT 2000)

The industry argued that tobacco control should be a national policy and warned of risks to state sovereignty from a binding international treaty: Properly regarded, international agreements are tools for responding to problems shared by many countries that cannot effectively be dealt with by sovereign governments acting alone. Problems like transboundary air and sea pollution, protection of migratory species, international navigation, and elimination of trade barriers simply cannot be addressed through unilateral action. Tobacco-related issues are different. They can be addressed at the national level (and even by political subdivisions of a nation) in a manner consistent with national sovereignty and country-specific policy choices. That is the level at which, and the manner in which, tobacco issues ought to be addressed.  (Brown and Williamson 2000)

Leading TTCs initiated Project Cerberus to develop ‘non-legally binding principles . . . sensible, politically feasible and the most workable approach to international and national tobacco regulation issues’ (Mamudu, Hammond, and Glantz, 2008). Through these strategies, the industry was able to influence the strength of some of the agreed provisions despite exclusion from the negotiations. With the desire to make the treaty palatable to the United States and other opposing countries, negotiators agreed to compromises to the final text. Whilst comprehensive in scope, few adopted measures were made obligatory. According to Assunta and Chapman (2004), this left member states ‘to decide how far to go in implementing the treaty’.

The Shift to Indirect Political Strategies: Old Foes, New Issues The FCTC was heralded as a major achievement in global health diplomacy after coming into force in 2005. Given the long-standing neglect of tobacco control, WHO was applauded for overcoming powerful vested interests to offer ‘the basic tools for countries to enact comprehensive tobacco control legislation’ (Assunta, Hammond, Stanton, and Sullivan 2004). To support parties in fulfilling their obligations, an FCTC Secretariat

Politics of Global Tobacco Control   673 was established, alongside the governing body of the FCTC, the Conference of the Parties (COP). Between 2005 and 2018 eight COP meetings were held to play ‘a range of critical roles . . . setting of normative standards, the building and dissemination of knowledge, the monitoring of implementation, the facilitation of international co­oper­ ation and the mobilisation of resources to support implementation’ (Liberman 2012). However, the politics of global tobacco control had entered a new phase. The unexpected decision by Brundtland to not seek re-election as WHO director-general and the departure of Yach (executive director of non-communicable diseases) and Vera Luisa da Costa e Silva (director of TFI) signaled an internal changing of the guard. The severe acute respiratory syndrome (SARS) outbreak in 2002–2003; new initiatives such as the Global Fund to Fight AIDS, Tuberculosis and Malaria in 2002; and emergence of the Bill and Melinda Gates Foundation as a leading funder drew the attention of the global public health community back to communicable diseases (Lee 2008). Funding for FCTC implementation, and for non-communicable diseases as a whole, remained comparably low despite accounting for 70 percent of deaths worldwide (WHO 2014).

FCTC Implementation: The Political Terrain Moves to States It is in this context that the political focus shifted to the country level, where public health advocates recognised the need for ‘swift and concerted action to bring the FCTC into force and ensure that countries implement it to the fullest [without which], there is a the danger that the treaty will end up as just a well-intentioned effort of interest to those studying the failure of international negotiations to bring about real improvements in public health’ (Hammond and Assunta  2003). The initial task of ratification by a requis­ite forty countries for the FCTC to come into effect suggested the industry had already shifted attention to member states. In Argentina, for example, Mejia and colleagues (2008) describe intense lobbying and strong-arm tactics to delay ratification: The principal strategy used by the TI [tobacco industry] was lobbying of provincial legislators and federal officials from the Ministry of the Economy by the tobacco growers associations. These legislators prevented the passage of comprehensive bills on tobacco control or of less comprehensive national laws. A typical legislative strategy used was to request additional analyses of the proposed bills from committees that prioritised economic issues over health. FCTC was mentioned in regional newspapers three to seven times per week in articles about alleged adverse economic effects of tobacco control. Direct physical threats to legislators who were openly supportive of FCTC ratification were made.

In Indonesia the minister of industry and trade urged ratification be postponed on the grounds that it could harm manufacturers and farmers (Anonymous 2004). In Brazil, whose diplomats prominently chaired FCTC negotiations, the BAT-funded Association of Tobacco Growers of Brazil lobbied to prevent ratification (INCA 2004).

674   Kelley Lee As ratification gave way to processes for adopting new national tobacco control legislation, industry pushed for weakened language to dilute the treaty’s intended strength. In Ecuador, where PMI dominates 87 percent of the cigarette market, an antitobacco law was adopted in 2006 that was ‘rendered significantly ineffective’ (Albuja and Daynard 2009). In Lebanon, new tobacco control legislation was narrow in scope and continually delayed (Nakkash and Lee 2009). In Japan, where the finance ministry formulated the country’s legislation, new policies were adopted to ban misleading labels but did not ban tobacco advertising outright (Simpson 2004). The industry also successfully pressed for ‘sensible’ and ‘appropriate’ regulation in the form of voluntary codes rather than binding legislation (Mamudu, Hammond, and Glantz  2008; Glantz, Mamudu, and Hammond, 2008) and initiated youth smoking prevention programmes of questionable intent (Assunta and Chapman 2004; Landman, Ling, and Glantz 2002). Similar industry-led efforts have been documented in Germany (Gruning and Gilmore  2007), Kenya (Patel, Collin, and Gilmore  2007) and Uzbekistan (Gilmore, Collin, and McKee 2006). The capacity of the industry to reassert political influence in low- and middle-income countries (LMICs) during this period stemmed in large part from the lack of new financial resources for treaty implementation. The US$10 million Rockefeller Foundation’s Trading Tobacco for Health Initiative, supporting tobacco control efforts in Southeast Asia, was a rare exception (Hamann  2000). Canada’s International Development Research Centre and the UK Department for International Development also provided small amounts of much-needed funding to LMICs to support tobacco control. A major boost was received in 2006 with the creation of the US$125 million Bloomberg Initiative to Reduce Tobacco Use by US businessman Michael Bloomberg, in partnership with WHO, Campaign for Tobacco Free Kids, and US Centers for Disease Control and Prevention (CDC), among others (WHO 2006). In 2008 an additional US$500 million of funding by the Bloomberg Philanthropies and Gates Foundation was announced. The sums represented the largest donor funding ever available for global tobacco control, which was initially used in large part to gather baseline and then longitudinal data through surveys of tobacco use by adults, youth, health professionals, and school personnel. The creation of the Global Tobacco Surveillance System (GTSS) led by the US CDC reinforced the role of data as a vital political tool to press for higher priority for tobacco control. The data also supported the scaling up of specific FCTC provisions into concrete actions centred on six proven measures, known as MPOWER (monitor, protect, offer, warn, enforce, raise) (WHO 2013). Funds helped to support local and regional tobacco control advocates, such as SEATCA and the Africa Tobacco Control Regional Initiative.

The Political Reinvention of the Tobacco Industry: An Aspiring Partner on illicit Trade and Harm Reduction Whilst public health and industry advocates adopted largely opposing positions regarding implementation of the FCTC, the politics of global tobacco control also saw

Politics of Global Tobacco Control   675 the emergence of a new political strategy by the tobacco industry during this period. High-profile litigation, the public release of internal industry documents, and a long stream of revelations about unethical and in some cases illegal practises left the tobacco industry at a low point in public reputation. The political influence of the industry depended on mending its reputation. These efforts focused on two key issues: the illicit tobacco trade and harm reduction. The illicit tobacco trade accounts for an estimated 9–11 percent of cigarettes consumed worldwide (FCA 2007). Given the impact of this trade on taxation and pricing policies, deemed to be among the most effective tobacco control measures, and the cross-border nature of this trade, the second COP agreed that it would be the subject of the first FCTC protocol. Negotiations commenced in 2008, and an agreement was adopted in 2012 that came into force in 2018 after ratification by forty countries. This prolonged process was in part due to limited expertise within the health sector on an issue that concerns law enforcement, customs and excise, and other policy areas beyond health. Given the nefarious nature of the trade, the lack of reliable and comprehensive data across countries over time also hindered agreement. There was also a lack of consensus on how best to address the problem. Both of these challenges afforded an opportunity for the tobacco industry to politically re-engage. Despite detailed scholarly analyses (Collin et al., 2004; Lee and Collin 2006; LeGresley et al. 2008; MacKenzie, Lee, and LeGresley 2016) and successful prosecution and substantial fining of leading TTCs regarding their complicity in the illicit tobacco trade (Beelman et al. 2000), the tobacco industry presented itself as a key partner. Alongside claims that previous practises were attributable to rogue employees, leading TTCs argued that ‘criminal gangs producing counterfeit cigarettes, smuggling across borders and engaging in large-scale tax evasion’ (BAT 2018) were harming their commercial interests. Given shared interests in reducing the illicit trade, the tobacco industry unsuccessfully argued for formal inclusion in proto­col negotiations. Excluded from negotiations, the industry turned to indirect strategies of political influence. One important strategy was to fill knowledge gaps on the illicit trade, which in turn influenced how the problem was understood and the preferred solutions. For example, leading TTCs funded studies to measure the volume of the trade and its main sources. In addition, the industry funded training of local customs and law enforcement officials, met with government officials, and sponsored meetings hosted by pro-industry think tanks. In many countries and regions, industry-supported research became the leading (and even sole) source of information. Through these activities, the industry was able to portray the problem and potential solutions in ways that served industry interests (Gallagher et al.  2018). For example, the industry repeatedly attributed the illicit trade to criminal organisations, indigenous peoples (Smith, Thompson, and Lee 2019), and terrorists despite evidence of its continued complicity (Gilmore, Gallagher, and Rowell 2018). By focusing on counterfeit cigarettes, leading TTCs also distracted attention from the substantial smuggling of authentic products, amounting to two-thirds of the illicit trade and involving ongoing industry complicity. The adoption of the track and trace system known as Coidentify as the preferred method of tackling the problem

676   Kelley Lee under the FCTC protocol illustrates the extent to which these strategies have enabled industry influence. As Gilmore, Gallagher, and Rowell (2018) describe: Philip Morris International (PMI) adapted its pack marker system, Coidentify, to meet T&T requirements, licenced it for free to its three major competitors who then collectively promoted it to governments using front groups and third parties including companies claiming to be independent despite clear TI links.

The reinvention of the tobacco industry as a legitimate stakeholder in public policy has also been an effective political strategy in relation to harm reduction. Harm reduction is a public health strategy that seeks to lower the health risks to individuals and populations through a variety of means, including potentially reduced-harm products. BAT and PMI, for example, have announced long-term business plans to move away from combustible products and towards new nicotine delivery systems that may pose a reduced health risk, led by electronic cigarettes and heated tobacco products. Since 2010 leading TTCs have heavily invested in the takeover of independent manufacturers and development of reduced-harm products (Mathers, Hawkins, and Lee 2019). In 2017 PMI announced the creation of the US$1 billion Foundation for a Smokefree World, led by the inaugural director of the TFI, ‘to raise our ambition for what is possible and desirable in tobacco control, and specifically in harm reduction from smoking’ (Yach 2017, 1807). Industry involvement in harm reduction has sharply divided the public health community. Whilst harm reduction is widely accepted as an important component of effective tobacco control policies, the extent to which the industry should be included as a legitimate contributor to harm reduction research and policy products is highly contested. As part of a strategy of ‘building trust for our products through science’, BAT launched its ‘2018 Harm Reduction Focus Report’, which demonstrates how the company is ‘committed to transforming tobacco by providing consumers with satisfying alternatives to smoking’ (BAT 2018). Similarly, PMI Science claims to conduct ‘rigorous scientific research that is the foundation of PMI’s RRPs [reduced-risk products]’ (Zielinski 2018). Given estimates that whilst 73 percent of regular smokers wish to quit, only 5 percent succeed without assistance (Etter, Perneger, and Ronchi 1997), supporters of industry involvement believe that accelerated use of such products will save millions of lives. In contrast, whilst recognising the importance of harm reduction, opponents decry the disingenuous nature of industry commitments amid continued large-scale marketing of combustible products by the same companies. Indeed, challenges to the adoption of selected tobacco control measures such as plain packaging, raised under trade and investment agreements, and national legislation show an industry still battling to sell combustible products (O’Dowd  2018). Similar to policy debates on the illicit tobacco trade, there is deep distrust of these efforts to repair the industry’s political legitimacy. As Peeters and Gilmore (2015, 182) note, harm reduction is ‘an opportunity to (re-)establish dialogue with and access to policy makers, scientists and public health groups and to secure reputational benefits via an emerging corporate social responsibility agenda’.’ BAT’s definition of harm reduction as ‘a well-established public health concept

Politics of Global Tobacco Control   677 that seeks pragmatic ways to minimise the impact of an inherently risky activity without stopping it entirely’ (BAT 2018) is seen as reflecting the industry’s ultimate goal of sustaining sales by promoting the use, and even ‘dual use’, of conventional and new nicotine products. PMI’s promotion of a smoke-free, rather than tobacco-free, world suggests a similar goal. The politics of global tobacco control, in short, has entered a new phase. The signing of the FCTC and illicit trade protocol, measures to minimise industry interference under Article 5.3, and public distrust of tobacco companies were major achievements for public health advocates. The self-rehabilitation of the tobacco industry and its partnerships with parts of the public health community have undermined some of these successes. Not least concerning have been the deep rifts created by the overtures, backed by substantial funding, to promote the industry’s research and policy agendas on selected tobacco control issues. There is also new evidence that the industry redoubled its work with think tanks (Smith, Thompson, and Lee 2017), chambers of commerce, academics, consultants, and others to further these agendas worldwide. The US$20 million STOP Initiative, announced in 2018 by the Bloomberg Philanthropies, was initiated as a response to industry interference in global tobacco control. There has also con­ tinued to be a disproportionately low share of resources allocated to tobacco control, and to non-communicable diseases generally, despite their accounting for more than half of all deaths worldwide (Benziger, Roth, and Moran 2016). There are continued efforts to shift attention from individual behaviours to societal-level risks, through such concepts as the ‘commercial determinants of health’ (Kickbusch, Allen, and Franz 2017). In this respect, fuller understanding of the politics of global tobacco control has never been more relevant.

Conclusion Understanding the long-standing anomaly of the regulatory frameworks governing the largest preventable cause of death worldwide begins with deeper scrutiny of the politics of global tobacco control. Initial efforts to bring the lethal effects of tobacco use to the attention of policymakers focused on the task of assembling scientific evidence. By the 1980s, as an increasingly globalised tobacco industry set its sights on expanding into emerging markets, it became clear that evidence-based arguments were insufficient. The political battle that ensued, to initiate, negotiate, and implement the FCTC, was hard fought. New evidence, generated alongside new allies, was central to WHO’s approach. Countering familiar arguments of a powerful industry and excluding it from ne­go­ti­ ations and public health policy were critical to advancing the public health agenda. The industry’s strategic investments in research and policy initiatives since 2005 that support industry interests, notably on the illicit trade and harm reduction, have begun to pay political dividends. In this context, maintaining tobacco control as a key global health priority, and in particular ensuring FCTC provisions are fully implemented, above all remain a political challenge.

678   Kelley Lee

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Politics of Global Tobacco Control   679 Cairney, Paul, and Mikine Yamazaki. 2017. ‘A Comparison of Tobacco Policy in the UK and Japan: If the Scientific Evidence Is Identical, Why Is There a Major Difference in Policy?’ Journal of Comparative Policy Analysis 20 (3): 253–268. Campaign for Tobacco Free Kids. 2018. ‘The Global Cigarette Industry.’ Washington, DC. https://www.tobaccofreekids.org/assets/global/pdfs/en/Global_Cigarette_Industry_ pdf.pdf. Chantornvong, Sombat, and Duncan McCargo. 2001. ‘Political Economy of Tobacco Control in Thailand.’ Tobacco Control 10 (1): 48–54. Ciresi, Michael, Roberta Walburn, and Tara Sutton. 1999. ‘Decades of Deceit: Document Discovery in the Minnesota Tobacco Litigation.’ William Mitchell Law Review 25: 477–566. Collin, Jeff, Kelley Lee, and Karen Bissell. 2002. ‘Negotiating the Framework Convention on Tobacco Control: The Politics of Global Health Governance.’ Third World Quarterly 23 (2): 265–282. Collin, Jeff, Eric LeGresley, Ross MacKenzie, Susan Lawrence, and Kelley Lee. 2004. ‘Complicity in Contraband: British American Tobacco and Cigarette Smuggling in Asia.’ Tobacco Control 13 (Supp. II): ii96–ii111. Crofton, John. 1990. ‘The Seventh World Conference on Tobacco and Health.’ Thorax 45 (7): 560–562. Cummings, Michael, and Robert Proctor. 2014. ‘The Changing Public Image of Smoking in the United States: 1964–2014.’ Cancer Epidemiology, Biomarkers and Prevention 23 (1): 32–36. Davies, Rob. 2017. ‘How Big Tobacco Has Survived Death and Taxes.’ Guardian, July 12. https:// www.theguardian.com/world/2017/jul/11/how-big-tobacco-has-survived-death-and-taxes. Doll, Richard, and Bradford Hill. 1954. ‘The Mortality of Doctors in Relation to Their Smoking Habits.’ BMJ 2: 1451–1455. ECOSOC. 1999. ‘Establishment of Ad Hoc Interagency Task Force on Tobacco Control.’ Resolution 1999/56. https://www.who.int/tobacco/global_interaction/un_taskforce/en/. Etter, Jean-François, Thomas Perneger, and Anne Ronchi. 1997. Distributions of Smokers by Stage: International Comparison and Association with Smoking Prevalence.’ Preventive Medicine 26 (4): 580–585. FCA. 2007. ‘FCA Recommendations: A Protocol on Illicit Trade in Tobacco Products.’ https://www.fctc.org/wp-content/uploads/2007/06/fca-2007-cop-illicit-trade-cop2-­ recommendations-en.pdf. Gallagher, Allen, Karen Evans-Reeves, Jenny Hatchard, and Anna Gilmore. 2018. ‘Tobacco Industry Data on Illicit Tobacco Trade: A Systematic Review of Existing Assessments.’ Tobacco Control, August 16. https://tobaccocontrol.bmj.com/content/tobaccocontrol/early /2018/08/16/tobaccocontrol-2018-054295.full.pdf. Gately, Iain. 2001. Tobacco: A Cultural History of How an Exotic Plant Seduced Civilization. London: Simon and Schuster. Gilmore, Anna, Jeff Collin, and Martin McKee. 2006. ‘British American Tobacco’s Erosion of Health Legislation in Uzbekistan.’ BMJ 332: 355–358. Gilmore, Anna, Allen Gallagher, and Andy Rowell. 2018. ‘Tobacco Industry’s Elaborate Attempts to Control a Global Track and Trace System and Fundamentally Undermine the Illicit Trade Protocol.’ Tobacco Control 28 (2). doi:10.1136/tobaccocontrol-2017-054191. Gilmore, Anna, and Martin McKee. 2004. ‘Moving East: How the Transnational Tobacco Industry Gained Entry to the Emerging Markets of the Former Soviet Union—Part I: Establishing Cigarette Imports.’ Tobacco Control 13 (2): 143–150.

680   Kelley Lee Glantz, Stanton, Hadii Mamudu, and Ross Hammond. 2008. ‘Tobacco Industry Attempts to Counter the World Bank Report Curbing the Epidemic and Obstruct the WHO Framework Convention on Tobacco Control.’ Social Science and Medicine 67 (11): 1690–1699. Godlee, Fiona. 1994. ‘The World Health Organization: The WHO in Crisis.’ BMJ 309: 1424. Grüning, Thilo, and Anna Gilmore. 2007. ‘Germany: Tobacco Industry Still Dictates Policy.’ Tobacco Control 16 (1): 2. Hamann, Stephen. 2000. ‘SE Asia: Rockefeller’s New Programme.’ Tobacco Control 9 (4): 361–362. Hammond, Ross, and Mary Assunta. 2003. ‘Editorial—The Framework Convention on Tobacco Control: Promising Start, Uncertain Future.’ Tobacco Control 12 (3): 241–242. Hu, The-Wei. 2013. ‘WHO Framework Convention on Tobacco Control in China: Barriers, Challenges and Recommendations.’ Global Health Promotion 20 (4): 13–22. INCA. 2004. A Ratificacao da Convencao-Quadro para o Controle do Tabaco pelo Brasil: Mitos e Verdades [Brazilian ratification of the Framework Convention on Tobacco Control: Myths and Truth]. São Paulo: Brazilian National Cancer Institute. http://bvsms.saude.gov .br/bvs/publicacoes/mitos_verdades.pdf. Jha, Prabhat, and Frank Chaloupka. 1999. Curbing the Epidemic: Governments and the Economics of Tobacco Control. Washington, DC: World Bank. Kaufman, Marc. 2001. ‘Negotiator in Global Tobacco Talks Quits Official Said to Chafe at Softer  U.S.  Stands.’ Washington Post, August 2. http://www.takingontobacco.org/letter /us0105u.html. Kickbusch, Ilona, Luke Allen, and Christian Franz. 2017. ‘The Commercial Determinants of Health.’ Lancet 4 (12): 895–896. Landman, Anne, Pamela Ling, and Stanton Glantz. 2002. ‘Tobacco Industry Youth Smoking Prevention Programs: Protecting the Industry and Hurting Tobacco Control.’ American Journal of Public Health 92 (6): 917–930. Lee, Kelley. 2008. The World Health Organization. London: Routledge. Lee, Kelley, Luiz Carlos Chagas, and Thomas Novotny 2010. ‘Brazil and the Framework Convention on Tobacco Control: Global Health Diplomacy as Soft Power.’ PLoS Medicine 7 (4): e1–e5. Lee, Kelley, and Jeff Collin. 2006. ’Key to the future’: British American Tobacco and cigarette smuggling in China. PLoS Medicine 3 (7): 228–237. LeGresley, Eric, Kelley Lee, Monique Muggli, Patel Patel, Jeff Collin, and Richard Hurt. 2008. ‘British American Tobacco and the “Insidious Impact of Illicit Trade” in Cigarettes in Africa.’ Tobacco Control 17 (5): 339–346. Liberman, Jonathan. 2012. ‘Four COPs and Counting: Achievements, Under achievements and Looming Challenges in the Early Life of the WHO FCTC Conference of the Parties.’ Tobacco Control 21 (2): 215–220. MacKenzie, Ross, Kelley Lee, and Eric LeGresley. 2016. ‘To ‘ “Enable Our Legal Product to Compete Effectively with the Transit Market”‘: British American Tobacco’s Strategies in Thailand Following the 1990 GATT Dispute.’ Global Public Health 11 (3): 348–362. Mamudu, Hadii, Ross Hammond, and Stanton Glantz. 2008. ‘Project Cerberus: Tobacco Industry Strategy to Create an Alternative to the Framework Convention on Tobacco Control.’ American Journal of Public Health 98 (9): 1630–1642. Mathers, Annalise, Benjamin Hawkins, and Kelley Lee. 2019. ‘Transnational Tobacco Companies and New Nicotine Delivery Systems.’ American Journal of Public Health 109 (2): 227–235.

Politics of Global Tobacco Control   681 Mejia, Raul, Véronica Schoj, Joaquin Barnoya, Maria Laura Flores, and Eliseo Pérez-Stable. 2008. ‘Tobacco Industry Strategies to Obstruct the FCTC in Argentina.’ CVD Prevention and Control 3 (4): 173–179. Muggli, Monique, Kelley Lee, Quan Gan, Jon Ebbert, and Richard Hurt. 2008. ‘Efforts to Reprioritise the Agenda’ in China: British American Tobacco’s Actions to Divert Health Policy from Secondhand Smoke to Liver Disease Prevention.’ PLoS Medicine 5 (12): 1729–1736. Nakkash, Rima, and Kelley Lee. 2008. ‘Smuggling as the “Key to a Combined Market”: British American Tobacco in Lebanon.’ Tobacco Control 17 (5): 324–331. Nakkash, Rima, and Kelley Lee. 2009. ‘The Tobacco Industry’s Thwarting of Marketing Restrictions and Health Warnings in Lebanon.’ Tobacco Control 18 (4): 310–316. O’Dowd, Adrian. 2018. ‘Latest Legal Challenge to Tobacco Plain Packaging Is Rejected by the World Trade Organization.’ BMJ 361: k2878. doi: https://doi.org/10.1136/bmj.k2878. Ong, Elisa, and Stanton Glantz. 2000. ‘Tobacco Industry Efforts Subverting International Agency for Research on Cancer’s Second-hand Smoke Study.’ Lancet 355 (9211): 1253–1259. Patel, Preeti, Jeff Collin, and Anna Gilmore. 2007. ‘ “The Law Was Actually Drafted by Us but the Government Is to Be Congratulated on Its Wise Actions”: British American Tobacco and Public Policy in Kenya.’ Tobacco Control 16 (1): e1. Peeters, Silvy, and Anne Gilmore. 2015. ‘Understanding the Emergence of the Tobacco Industry’s Use of the Term Tobacco Harm Reduction in Order to Inform Public Health Policy.’ Tobacco Control 24 (2): 182–189. Peto, Richard, Alan Lopez, Jillian Boreham, Michael Thun, and Clark Heath. 1996. ‘Mortality from Smoking in Developed Countries 1950–2000: Indirect Estimates from National Vital Statistics.’ American Journal of Epidemiology 143 (5): 529–530. PM. 1996. ‘The Activist Movement.’ August. https://www.industrydocumentslibrary.ucsf.edu /tobacco/docs/#id=txcb0123. Roemer, Ruth, Allyn Taylor, and Jean Lariviere. 2005. ‘Origins of the WHO Framework Convention on Tobacco Control.’ American Journal of Public Health 95 (6): 936–938. Shepherd, Philip. 1985. ‘Transnational Corporations and the International Cigarette Industry.’ In Profits, Progress and Poverty: Case Studies of International Industries in Latin America, edited by R. Newfarmer, 63–113. Notre Dame, IN: University of Notre Dame Press. Simpson, David. 2004. ‘FCTC: How Will They Keep Pushing?’ Tobacco Control 13(3): 216–217. Smith, Julia, and Kelley Lee. 2016. ‘ “Public Enemy No. 1”? HIV/AIDS and Tobacco Industry Funding.’ SAHARA-J: Journal of Social Aspects of HIV/AIDS 13(1): 41–52. Smith, Julia, Sheryl Thompson, and Kelley Lee. 2017. ‘The Atlas Network: A “Strategic Ally” for the Tobacco Industry.’ International Journal of Health Planning and Management 32 (4): 433–448. Smith, Julia, Sheryl Thompson, and Kelley Lee. 2019. ‘Both Sides of the Argument? What We Do Not Know about the Illicit Tobacco Trade in Canada.’ Tobacco Control. doi:10.1136 /tobaccocontrol-2018-054687. Studlar, Dudley. 2002. Tobacco Control: Comparative Politics in the United States and Canada. Toronto: University of Toronto Press. Studlar, Dudley, and Paul Cairney. 2014. ‘Conceptualizing Punctuated and Non-punctuated Policy Change: Tobacco Control in Comparative Perspective.’ International Review of Administrative Science 80 (3): 513–531. Taylor, Allyn. 1992. ‘Making the World Health Organization Work: A Legal Framework for Universal Access to the Conditions for Health.’ American Journal of Law and Medicine 18 (4): 301–346.

682   Kelley Lee Taylor, Allyn, and Daniel Bodansky. 1998. The Development of the WHO Framework Convention on Tobacco Control: Legal and Policy Considerations. Geneva: Tobacco Free Initiative. Tiffin, Norman. 2015. ‘Why Do We Still Permit Tobacco Use?’ Canadian Journal of Respiratory Therapy 51 (4): 85. Tobacco Manufacturers Association. 2000. ‘WHO Treaty Negotiations.’ October 20. http:// legacy.library.ucsf.edu/tid/ieh85a00/pdf?search=%22fctc%20negotiations%20world%20 health%20organization%22. US Surgeon General. 1964. Smoking and Health, Report of the Advisory Committee to the Surgeon General of the Public Health Service. Washington, DC: US Department of Health, Education, and Welfare. https://profiles.nlm.nih.gov/ps/access/NNBBMQ.pdf. Vaughan, Patrick, Sigrun Mogedal, Stein-Erik Kruse, Kelley Lee, Gill Walt, and K. de Wilde. 1996. ‘Financing the World Health Organization: Global Importance of Extrabudgetary Funds.’ Health Policy 35 (3): 229–245. Vecchiet, Andreas. 2000. ‘IPA Project Brief.’ British American Tobacco, August 10. http:// legacy.library.ucsf.edu/tid/uyz24a99/pdf?search=%22fctc%20negotiations%20world%20 health%20organization%22. Webb, William. 1988. ‘1988 Board Presentation—Asia/Australia Outlook.’ PMI, August 3. https://www.industrydocumentslibrary.ucsf.edu/tobacco/docs/#id=mjkd0116. WHO. 1988. ‘Smokeless Tobacco Control: Report of a WHO Study Group.’ Technical Report  Series 773. Geneva. https://apps.who.int/iris/bitstream/handle/10665/39026/ WHO_TRS_773.pdf?sequence=1&isAllowed=y. WHO. 1995. ‘An International Strategy for Tobacco Control.’ WHA 48.11 Resolution, 12th Plenary, Geneva, May 12. https://www.who.int/tobacco/framework/wha_eb/wha48_11/en/. WHO. 1996. ‘An International Framework Convention for Tobacco Control.’ Executive Board Resolution EB97.R8, Geneva. WHO. 2000. ‘Tobacco Industry Strategies to Undermine Tobacco Control Activities at the World Health Organization.’ Committee of Experts on Tobacco Industry Documents, Geneva. http://www.who.int/tobacco/en/who_inquiry.pdf. WHO. 2006. ‘WHO Named as One of Five Partners to Implement Michael Bloomberg’s $125 Million Initiative to Promote Freedom from Smoking.’ Press Release, November 3. http:// www.who.int/mediacentre/news/statements/2006/s16/en/index.html. WHO. 2008. WHO Report on the Global Tobacco Epidemic, 2008, The MPower package. Geneva: Tobacco Free Initiative. https://www.who.int/tobacco/mpower/mpower_report_ full_2008.pdf. WHO. 2013. ‘MPOWER in Action: Defeating the Global Tobacco Epidemic.’ Geneva: Tobacco Free Initiative. https://www.who.int/tobacco/mpower/publications/mpower_2013.pdf?ua=1. WHO. 2014. ‘Global Status Report on Noncommunicable Diseases.’ Geneva. https://apps.who. int/iris/bitstream/handle/10665/148114/9789241564854_eng.pdf;jsessionid=D8A5B706C20 3B1EFA7717EBB69E65718?sequence=1. WHO/EMRO. 2004. ‘Tactics and Plans to Undermine Tobacco Control.’ Regional Office for the Eastern Mediterranean. http://www.emro.who.int/tfi/pdf/TFI-020-Part2.pdf. Wipfli, Heather. 2015. The Global War on Tobacco: Mapping the World’s First Public Health Treaty. Baltimore, MD: Johns Hopkins University Press. World Economic Forum. n.d. ‘Frequently Asked Questions.’ https://www.weforum.org/ open-forum/pages/faq.

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chapter 34

The Politics of Gl oba l Bioethica l Fr a m ewor ks Diego S. Silva and Jeremy Snyder

The globalisation of medical research, health services, knowledge translation, and other facets of the health sector has led to an interest in articulating ethical norms that are universal in scope and thus have the potential to apply across these and other global practises. The United Nations Educational, Scientific, and Cultural Organization (UNESCO) ‘Universal Declaration on Bioethics and Human Rights’ (UDBHR) (UNESCO 2005), aims to articulate such universal bioethical norms (Trotter 2009). This declaration stemmed from UNESCO’s mission to describe international standards for the social and human sciences. Motivated by this mission, UNESCO sought to determine whether the field of bioethics was subject to universal norms (Snead 2009). From the start, UNESCO’s General Conference sought a balanced document that sets universal standards for such concepts as human dignity, freedom, and human rights, whilst remaining compatible with cultural pluralism (UNESCO 2005). The UDBHR has been praised for achieving a first step towards the goal of establishing a minimum standard of ethical conduct for biomedical research and clinical practise (Andorno 2007). However, it has also come under significant and sustained criticism, on grounds ranging from whether UNESCO has the jurisdiction to create and promote such a declaration in the first place to the content of the principles espoused in the declaration (Benatar 2005). The process behind the UDBHR’s development has been critiqued as well, including concerns that the drafters of the declaration lacked regional and ideological diversity, legal experts were over-represented relative to bioethicists, the document lacked philosophical rigour, member states were not properly consulted during the process of development, the development process lacked transparency, and

686   Diego S. Silva and Jeremy Snyder the goal of consensus undermined the elaboration of the bioethical principles espoused (Snead 2009). In this chapter we discuss the two key political issues raised by the development of the UDBHR: the legitimacy of this declaration and the universality of its application. We look specifically at an issue that confronts any attempt to develop a global bioethical framework: the tension in documenting norms that are applicable universally without being so minimal in scope or vague in content as to be of little or no use to bioethicists, health practitioners and advocates, and policymakers. The UDBHR recognises cultural diversity whilst applying what it purports to be universal bioethical principles. Thus, determining the legitimacy of the UDBHR depends in part on whether one can balance the conceptual tension between the idea of cultural diversity (understood as either pluralism or relativism) and universal moral values and norms. First, we define key terms to assess the legitimacy and coherence of the UDBHR, namely universalism, relativism, pluralism, and legitimacy. Whilst these terms are commonly used in discussion of the UDBHR and of ethical principles generally, they often go undefined, creating confusion and discussion at cross purposes. Second, we provide a brief history of the UDBHR and how it fits with the other international efforts to outline ethical principles and procedures for clinical research and healthcare. Third, we discuss the political questions of the universality of the UDBHR in the context of cultural diversity, and the legitimacy of UNESCO in advancing it, by closely analysing the text of the UDBHR. Finally, we outline some future steps that would promote the universality and legitimacy of the UDBHR. These include adding philosophical rigour to the declaration by making explicit its relationship to the key terms discussed in this chapter. Moreover, the legitimacy of the UDBHR can be increased by specifying the general principles contained in it through developing local iterations of the declaration that appeal to diverse regional, cultural, and ethnic traditions whilst supporting the universal scope of the UDBHR.

Defining Key Terms Before discussing the key political issues of legitimacy and universality raised by the development of the UDBHR, it is important to provide some provisional definitions of key terms. These remain subject to debate and have been the subject of thousands of years of analysis. Thus, whilst these definitions provide a clearer sense of how terms are used in this chapter, we do not purport to provide definitive conclusions about how they should be best understood. Whilst much more has been written about all four of these ideas and their histories in political and moral philosophy, this overview should be sufficient for a discussion of the relevance of these concepts to the UDBHR. First, universalism (in the context of moral and political philosophy) refers to the idea that certain ethical and political norms apply to all people across all of human history. For example, the idea that killing is, generally speaking, ethically bad or wrong means that

Politics of Global Bioethical Frameworks   687 killing is bad or wrong regardless of where in the world one might live and regardless of the epoch in which one lives. For the sake of clarity, it is important to distinguish universalism from generalism; the latter refers to the extent to which a particular norm holds, more or less often, and what conditions may come about to serve as an exception to the general form of the norm, in favour of or against a particular thing. For example, in general, killing is bad or wrong, but killing in self-defense is morally permissible (i.e., there are particular circumstances when the general moral norm does not apply). One can state that the permissibility of killing in self-defense, and its being an exception to the rule, hold universally (i.e., regardless of time or geography). Second, relativism is the idea that moral norms cannot be or ought not to be understood universally. Thus, relativism stands in contrast to the idea of universalism. Two versions of relativism are most commonly invoked. Cultural relativism is the idea that norms, including ethical values and norms, are created and can only be understood in the context of a person’s or group’s culture, and that because there have been many different cultures across history, there are many different sets of ethical values and norms that may or may not cohere. Moral (or ethical) relativism is the idea that we ought not to promote universal moral norms because there are no objective and universal moral norms. Thus, cultural relativism is descriptive, whereas moral relativism is prescriptive (although it, too, is based in part on a description, namely, the purported fact that no objective and universal moral norms exist). Third, pluralism refers to the idea that reasonable people (adopting a common-sense notion of reasonable, itself open to much debate) will disagree about important metaphysical or epistemological beliefs, as well as ethical values and norms. Pluralism is assumed to be a brute reality of living in democracies and a multicultural world. The challenge is to determine how citizens and residents of democratic states might best function and interact despite, and potentially thrive because of, pluralism. It is important to note that pluralism is different from relativism. One may coherently maintain that there are universal ethical norms, but (a) we cannot agree on their detailed application in practise (e.g., killing is bad or wrong, but how to apply this rule is open to debate), or (b) we can agree on a certain subset of moral rules (e.g., appeals to procedural justice or to acceptance of certain liberal beliefs) so that we can coexist with others who do not accept our overall set of moral beliefs. Finally, legitimacy (in the context of moral and political philosophy) refers to the conditions in which an agent x is permitted or obligated to act in manner y, but regardless of how good or right y is, z is not permitted to carry out y. A classic example is punishment for a crime. It is generally understood that if a person is found guilty of a crime, for example assault, the state is the only agent that can legitimately punish the criminal. One might perhaps argue that the person who has been assaulted may be morally justified in seeking to punish the criminal or get revenge. However, punishment on the part of private citizens is generally considered an illegitimate form of redress. Discussion about legitimacy, and who constitutes a legitimate actor, when, and under what conditions, has been a key focal point of twentieth- and twenty-first-century political philosophy, particularly in the context of democracies that are subject to pluralism. Stated differently, if

688   Diego S. Silva and Jeremy Snyder one accepts pluralism as true and part of what it means to live in a democratic state, then understanding the moral and practical complexity of who can legitimately govern, how, and on what grounds becomes of paramount importance.

A Brief History of UDBHR and Other Ethics Declarations in Clinical Research and Healthcare International bioethics frameworks and declarations (including guidelines and codes) first focused on the ethics of clinical research. These agreements were reached following the end of World War II and the Nuremberg trials. As part of those trials, Allied Forces prosecuted high-ranking members of the Nazi Party, and in 1946–1947 doctors working under the regime were tried for torture and murder as a result of the experiments they had conducted. From these trials the Nuremberg Code was developed, which outlines ten rules that doctors must follow when conducting research, including the need for voluntary consent of the subject and the avoidance of unnecessary pain or suffering (Annas and Grodin 2008). In 1948 the World Medical Association (WMA), a physicians’ advocacy group, adopted the Declaration of Geneva, which outlines virtues that doctors must have and follow whilst practising medicine (e.g., ‘I will practise my profession with conscience and dignity’) (WMA 2006). Perhaps more notably, the WMA produced the first iteration of the Declaration of Helsinki in 1964, which outlines the responsibilities of doctors as researchers. The agreement includes perhaps the first discussion on the importance of the proportionality of the risks and benefits of research for subjects (Ashcroft 2008). Following these foundational international research ethics documents, in 1982 the Council for International Organizations of Medical Sciences (CIOMS) produced the highly influential ‘International Ethical Guidelines for Biomedical Research Involving Human Subjects’ (most recently updated in 2016). The CIOMS is a not-for-profit organisation established by the World Health Organization (WHO) and UNESCO in 1949 (CIOMS 2016). For our purposes, it is worth noting that all these declarations and guidelines, either explicitly or implicitly, provide doctors and the broader medical community with universal ethical norms, principles, values, or virtues to direct their research and practise. As such, all these documents must contend with the dialectic between universalism and pluralism and that of universalism and relativism, whilst also answering questions about the legitimacy of the organisations and processes that create these declarations and guidelines. For example, the 2002 revision of the CIOMS guidelines explicitly states that the ‘challenge to international research ethics is to apply universal ethical principles to biomedical research in a multicultural world with a multiplicity of health-care systems and considerable variation in standards of health care’ (CIOMS 2002). The 2016 revision of the CIOMS guidelines maintains this universalist perspective whilst also implicitly

Politics of Global Bioethical Frameworks   689 addressing issues of legitimacy by describing the global makeup of the committee that reviewed and revised the guidelines, its close partnership with WHO, and the efforts at international consultation (CIOMS 2016). The history, process, and challenges associated with the drafting of the UDBHR (a declaration that encompasses not only research but also healthcare practise) are described elsewhere (Macpherson 2007; Snead 2009; Langlois 2011; ten Have 2016; Stanton-Jean 2016). Briefly, it is worth noting that the drafters of the UDBHR also struggled with questions about universalism, pluralism, relativism, and legitimacy. Still, some authors have argued that UNESCO is well situated to lead any attempts at developing a universal declaration because the bioethics arm of UNESCO brings together the various moral perspectives of all its members (ten Have 2016) and the UDBHR is seen by the members of UNESCO itself as articulating merely broad, general principles that are open to future revision (Stanton-Jean 2016). However, particularly important questions and criticisms remain about the process undertaken to reach the final version of the UDBHR and how that may affect the legitimacy of the declaration. Some have criticised the composition of the drafting body as being too slanted towards human rights law and away from bioethics perspectives, the transparency of the meetings and debates between the drafters, and the willingness of the original drafters of the UDBHR to take into account the concerns of the country delegates of UNESCO (Snead 2009). Other authors have called into question the lack of public consultation with the broader bioethics community (Macpherson 2007; Langlois 2011). We set aside this pertinent historical debate and in the next section we provide a close textual analysis of the UDBHR to see if and how these practically and politically important issues are addressed by the language used in the document.

The Politics of Universality and Legitimacy Regarding the ‘Universal Declaration on Bioethics and Human Rights’ Two of the key political issues raised by the development of the UDBHR are the universality and legitimacy of this document and the process through which it was developed. The first of the eight aims of the UDBHR is ‘to provide a universal framework of principles and procedures to guide States in the formulation of their legislation, policies or other instruments in the field of bioethics’. Thus, from the outset the writers and signatories of the UDBHR adopt a universalist position regarding the ethical principles and procedures that should guide the entirety of bioethics. In bioethics, principles are often considered mid-level norms or rules, so that presumably all persons can hold them universally precisely because they do not appeal to any particular moral theory but are still

690   Diego S. Silva and Jeremy Snyder action guiding. Stated differently, regardless of whether one is a classical utilitarian, is a Kantian, or abides by rules of Confucianism, all can agree that principles, such as autonomy and beneficence, are important and ought to be promoted in the context of biology and health. Debate may still remain about how to balance these principles in specific contexts. Likewise, an appeal to procedures is an appeal to rules about how one ought to go about doing bioethics. For example, if we (i.e., a group of reasonable persons) cannot agree about what moral ends ought to guide the allocation of scarce resources, then we should at least agree on the rules for fair allocation, so that regardless of the ultimate outcome of allocative decisions (e.g., regardless of whether a particular resource is distributed on the basis of greatest need or greatest utility), everyone can agree that the decision was made in a fair manner. Thus, by appealing to principles and procedures, the universality espoused at the outset of the UDBHR implicitly accepts and potentially endorses pluralism. In other words, the writers and signatories of the UDBHR seem to acknowledge that there can be reasonable disagreement about what moral theories are sound. In response, it places the idea of universality, not at the level of moral theory or some overall set of moral beliefs, but rather at a level where its adherents presume everyone can agree—namely, at the level of principles and procedures. What the writers and signatories of UDBHR accept as the implicit truism of pluralism in their articulation of the aims of the document, they make explicit in the preamble, specifically in Article 12. In the preamble we see that members of UNESCO believe that it is permitted to write the UDBHR, ‘[c]onsidering UNESCO’s role in identifying universal principles based on shared ethical values to guide scientific and technological development and social transformation’. We might draw three conclusions from this passage. First, members of UNESCO believe that there are such things as universal principles, which is in keeping with the aim of the UDBHR described in the preceding paragraph, as well as some form of pluralism. Second, members of UNESCO hold that these universal principles are grounded in ‘shared ethical values’. It is unclear, however, exactly what is meant by this phrase as used here. Do the writers and signatories believe there are moral beliefs more fundamental than the principles that ground those of the UDBHR? If so, are these more fundamental ethical values (whatever they are) shared by those who hold different ethical theories? Third, from this brief passage we can begin to deduce UNESCO’s claim and defense of the very legitimacy of the UDBHR itself, namely, that UNESCO sees as part of its role the very identification of universal moral principles in the context of science and human health. Thus, if part of the mandate of UNESCO is to identify and write about universal moral values, then it has a prima facie claim that it can legitimately write a bioethics declaration that the whole world ought to follow. Those working at UNESCO, and with UNESCO, therefore believe that it can legitimately create a document about the universality of moral principles and procedure in bioethics. Whether or not UNESCO actually holds such a mandate, and if not, whether it ought to have such a mandate, are key political questions raised by this claim. In the preamble we also see UNESCO’s first description of what cultural diversity is and its role in the UDBHR and bioethics more broadly. The writers of the UDBHR state: ‘[b]earing in mind that cultural diversity, as a source of exchange, innovation

Politics of Global Bioethical Frameworks   691 and creativity, is necessary to humankind and, in this sense, is the common heritage of humanity, but emphasising that it may not be invoked at the expense of human rights and fundamental freedoms’. First, cultural diversity is understood as the means of exchanging ideas, presumably, and as a source of creativity. It is represented as ‘the common heritage of humanity’, perhaps suggesting that the diversity of thoughts that exists between people and cultures is part of what it means to be human. Regardless of the accuracy of the interpretation of this passage, the writers and signatories of the UDBHR appear to hold cultural diversity as, on the whole, a good thing that ought to be promoted. And yet cultural diversity comes second to human rights and fundamental freedoms. Here we come up against a potential tension in the UDBHR, namely the exact nature of the interplay between ethics and human rights (Andorno 2009). This passage states that cultural diversity ought not to supersede fundamental human rights, such as security of the person and equality regardless of race or gender. It would seem that the respect afforded cultural diversity can itself be grounded in fundamental human rights, at least as articulated in Articles 18 and 19 of the ‘Universal Declaration of Human Rights’ (UN General Assembly 1948). This leads to controversial political questions about how the various fundamental rights ought to be interpreted in light of each other, a topic discussed at length in the existing literature (Donnelly 2013). Under a charitable reading of the UDBHR, one might rearticulate this passage using ethics language and conclude that appeals to cultural diversity cannot be used to unjustifiably harm persons and their basic interests or well-being. Article 12 of the UDBHR reiterates the ideas of the passage from the preamble presented in the preceding paragraph, but adds the idea of pluralism. Article 12 reads: ‘The importance of cultural diversity and pluralism should be given due regard. However, such considerations are not to be invoked to infringe upon human dignity, human rights and fundamental freedoms, nor upon the principles set out in this Declaration, nor to limit their scope’. At first it would seem that the basic sentiment of this article is a reiteration of the section found in the preamble. There is the invocation of cultural diversity and how it is important and should be respected, but that it cannot be used to infringe upon basic human rights (which again can be charitably reread to include ideas commonly found in ethics). Certain additions are made to this reiteration, namely that cultural diversity cannot be used to infringe upon the principles set out in the UDBHR. This would seem to follow from the logic of the document, that if the principles of the UDBHR are based on (to some degree) and are meant to cohere with basic human rights as articulated in other declarations and covenants of the United Nations, and that cultural diversity cannot be used to infringe human rights and fundamental freedoms, then cultural diversity cannot be used to justify infringements of the principles of the UDBHR. However, Article 12 not only deals with cultural diversity but also explicitly introduces pluralism for the first time in the document. Pluralism might thus be interpreted as being set apart, and held as distinct, from the idea of cultural diversity. Two questions quickly arise: What did the writers and signatories of the UDBHR mean by pluralism? And what are the differences between pluralism and cultural diversity?

692   Diego S. Silva and Jeremy Snyder It is not clear to us how the writers of the UDBHR would answer these two questions. One possible response is to define pluralism in a manner that is commonly used in moral and political philosophy, as outlined in the previous section—namely, that reasonable people will reasonably disagree about metaphysical and epistemological beliefs, and (most important for our purposes) ethical values and norms. Pluralism could then be contrasted with an understanding of cultural diversity as cultural relativism, which is the idea that norms, including ethical values and norms, are created and can only be understood in the context of a person’s or group’s culture and, since there are many different sets of cultures, the multitude of ethical values and norms that may or may not cohere. Crucially, significant political problems are created for the adoption and legitimacy of the UDBHR if Article 12, and subsequently the entirety of the UDBHR, if it can be interpreted as recognising not only pluralism but also cultural diversity as cultural relativism. That is because the embrace of pluralism and cultural relativism makes it unclear how the writers and signatories to the UDBHR can make sense of the universality of principles and procedures. At its most basic, universalism (the idea that norms can be universalised) lies in contradiction to any form of relativism (the idea that norms cannot be universalised), including cultural relativism. One might object to the validity of this concern by arguing that the use of cultural diversity (as relativism) alluded to in the UDBHR rests at the level of moral theory, but that maintaining cultural relativism is consistent with upholding the universality of mid-level principles and procedures; as such, there is no contradiction because each idea, cultural diversity or universalism, refers to a different thing altogether. However, as discussed previously, the UDBHR refers to the ‘shared ethical values’ upon which the universal principles of the document are founded. True, it is unclear what exactly the writers of the UDBHR mean by the phrase ‘shared ethical values’, but if it were to mean that the universal principles are based on some other, more foundational values or norms that are themselves universal, then it behoves the writers of the UDBHR to clarify what exactly is referred to by the invocation of ‘shared ethical values’ and how this does not collapse into a contradiction between cultural relativism and universalism. Moreover, allowing for the possibility of coexistence between cultural relativism and universalism requires us to carefully explain why we ought to believe that relativism only exists at the level of moral theory and not principles. It is unclear what the details of such an explanation would be. It seems we could argue that cultural differences only exist at some foundational levels with regard to theory-driven values and norms but that universality is otherwise possible, but then this would seem to at best collapse into pluralism (again, the idea that reasonable disagreement exists about moral values and norms without rejecting universalism). Moreover, if cultural relativism is sound, then the universality of mid-level principles is contingent upon not finding any cultures that disagree with the principles themselves, which is at best a weak conclusion. Promoters of the UDBHR may also note that it is fundamentally a political document; it is not intended to be a philosophical treatise and therefore should not be held to

Politics of Global Bioethical Frameworks   693 the same rigour as traditional philosophical arguments. Cultural diversity just means pluralism, or is a subset of pluralism (Revel 2009), and there is an unfortunate redundancy in how Article 12 was written. In other words, the very nature of such documents, with so many authors and signatories and governments to please, makes it impossible (or highly improbable) to reach any kind of precision in language and argumentation that makes it worth reading with too much attention to detail. Benatar (2005), for example, has criticised the UDBHR precisely for being too minimalist and vague; the ideas therein are intentionally written so that it actually says very little; all member states can reconcile it with their values and perhaps adopt the declaration. But perhaps having such a declaration, despite its limitations due to being minimalist and vague, is still worthwhile. As ten Have (2016, 7) notes, ‘the request to develop normative instruments frequently originates from developing countries. Since they have no, or weak, infrastructures in the field of bioethics, they often are concerned that they may not be able to participate in scientific and technological developments or that they will be confronted with the negative fall-outs’. As such, instruments such as the UDBHR serve the interests of those most vulnerable states (i.e., low-income countries) and those people who are most vulnerable within those states. Whether or not such instruments provide any real benefit to low-income countries is an empirical question that falls beyond the scope of this chapter. Still, the original objection remains: the purpose of the UDBHR is not to appease the philosophers of bioethics but rather to exist as a political instrument that protects all people and promotes ethical development of science for the sake of improvements in health; as such, any logical inconsistencies, if sufficiently minor (such as using cultural diversity to refer only to pluralism), should be ignored. Moreover, political arguments in support of UNESCO’s legitimacy in writing a declaration on bioethics in the first place lean on the idea that maintaining some consistency between the idea of cultural diversity (understood charitably) and the universality of principles and procedures is necessary. In writing about her involvement in the process of drafting and conducting consultations on the UDBHR as chair of the International Bioethics Committee at UNESCO, Stanton-Jean (2016, 14) notes: ‘I thought that it was a great moment for Bioethics. For the first time a global political statement in the field of Bioethics was adopted by all member states of UNESCO’. The fact that all member states accepted the document would seem to bode well for the document’s legitimacy. However, the adoption itself is based on balancing cultural diversity with universalism. Citing former director general of UNESCO Kōichirō Matsuura, Stanton-Jean (2016) points out that the reason the UDBHR is a declaration and not a covenant (where the former is generally understood as providing very important recommendations that take the force of soft law, as opposed to the latter, which are binding agreements between signatories) is the recognition on the part of the writers and signatories that global bioethics is complex and must take into account a wide variety of cultural contexts. Moreover, she notes (again citing Matsuura) that the principles are written in a broad manner, so that all member states can accept and see themselves in the UDBHR, given the global nature of health research and delivery. Thus, the nature of the UDBHR as a declaration

694   Diego S. Silva and Jeremy Snyder might be interpreted as speaking to the idea of a cultural diversity, whilst articulating broad (perhaps ‘vague’ to use the language of Benatar) principles that are used to retain a sense of universality. The politics of the drafting of the UDBHR, however, do problematize this conclusion. Even if it is true that all member states accept the UDBHR, this does not tell us that the declaration was written in a manner that is genuinely inclusive of all cultural viewpoints and does not ensure that some member states, perhaps those with less global power, did not feel pressured to accept its principles and procedures (Macpherson 2007) (assuming, for the sake of argument, that inclusiveness and making decisions in the absence of pressure confer an ethically acceptable form of agreement). This may very well be the case. Again, however, much like the question about how successful the UDBHR is in practise, this is an empirical question within the purview of historians, anthropologists, and sociologists. Research on this question, as far as we know, has not been extensively conducted, but we would certainly welcome it. For now, unless evidence to the contrary is presented, the benefit of the doubt should go to the writers and signatories of the UDBHR. The legitimacy of the UDBHR may also rest, in part, on whether one accepts the very mandate of UNESCO itself. ten Have (2016, 6) notes that ever since Julian Huxley, the first director general of UNESCO, the organisation’s ‘mission and its mandated work in the areas of education, culture, science and communication, the organisation from the start emphasised its role as “moral conscience” ’. Since its beginnings, therefore, UNESCO has seen the articulation of values that are acceptable to all member states as part of its mandate. This would be in keeping with the language of the preamble, discussed previously, namely that UNESCO has a ‘role in identifying universal principles based on shared ethical values’ (UNDBHR). ten Have also notes that ‘UNESCO is a global platform for bioethics that brings together moral perspectives from all countries on an equal basis (at least in principle since in practise some member states will be more involved than others). This is easier said than done’ (ten Have 2016, 7). He states that ‘the major challenge [for the International Bioethics Committee] is always to reconcile an aspiring universal discourse with respecting local diversity’ (ten Have 2016, 7). Thus there exists recognition of the tension between cultural diversity (as pluralism) and universalism, which needs to be balanced, and that eschews any simple answers or solutions. Again, how well this is done in practise requires further investigation, but it is at least heartening that the tension is acknowledged by the International Bioethics Committee and UNESCO, rather than merely ignored. In summary, a charitable reading of the UNDBHR suggests that the writers and signatories wanted to promote a culturally relevant and diverse interpretation of universal bioethical principles and procedures, whereby the idea is to be sensitive to the differences between cultures and countries with regard to the very nature of ethics and bioethics, without collapsing into any sort of relativism. The legitimacy of the UNDBHR rests in part on acceptance of (a) such universality existing and (b) UNESCO being the appropriate place to discuss universal ethics values, norms, and principles, which it seems UNESCO believes it has the authority to do.

Politics of Global Bioethical Frameworks   695

Moving Forward on Universal Bioethical Principles Whilst remaining neutral about the desirability of UNESCO, or any other international group, developing and promoting universal bioethical principles, in the remainder of this chapter we wish to suggest some steps that would increase the cogency and legitimacy of any such endeavour. First, any such document must be philosophically rigorous, in the sense that it should be clear and consistent in its use of terminology and concepts drawn from philosophical ethics and political theory. As our discussion has shown, fundamental terms such as pluralism, universalism, and relativism have complex and often contested meanings built on a long tradition of ethics scholarship. The failure to connect the use of these terms to this history and to stipulate their meaning clearly in such a document all but ensures that the response to any declaration of bioethical principles is likely to focus on debates over its meaning and validity rather than on its promotion and enforcement. This is not to say that a declaration such as the UDBHR should devote extensive space to engaging in meta-ethical debates over the meaning of core ethics concepts; rather, clarity is needed about the understanding of these concepts for the purpose of any declaration, either in the declaration itself or in a companion document. This is true not only for overarching concepts such as universality, but also for those key concepts that make up the substance of the declaration. For example, Article 10 of the declaration maintains that humans should be understood as having fundamental equality with one another in terms of their dignity and rights ‘so that they are treated justly and equitably’. As stated, it is unclear how justice and equity are meant to be understood for the purpose of the declaration and how they relate to one another. Are these two ways of saying the same thing or distinct concepts with important differences? If the former, are they to be understood as shorthand for equality of dignity and rights or to be understood differently? If the latter, how are these two concepts differentiated, and are they compatible with one another and with equality of dignity and rights? These are fundamental questions, drawn from a long history of debate in ethics and political theory. Without linking these concepts to a specific interpretation of their meaning, any declaration is likely to mean everything to everyone whilst failing to offer guidance in important areas of contention in global bioethics. As a second step, UNESCO and other bodies can promote the development, legitimisation, and use of universal bioethical principles by supporting smaller declarations and documents that span regions or cultural or ethnic groups. This approach might seem counterintuitive, as declarations by regional or cultural groups have the potential to be at odds with one another, thus supporting a view of bioethics as relativistic rather than universal. However, there are important advantages to this approach for defenders of universalism in bioethics. A significant benefit of these regionally and culturally specific declarations is that they would allow for the specification of universal values. That is,

696   Diego S. Silva and Jeremy Snyder they would allow these groups to take a fairly vague principle such as the UDBHR’s Article 13 (‘Solidarity amongst human beings and international cooperation towards that end are to be encouraged’) and address this vagueness by adding substance to the meaning of ‘solidarity’ and practical suggestions about how to promote this value. This proc­ess of specification to local context supports rather than threatens the goal of universalism by demonstrating how the general but necessarily vague principles ­outlined in the UDBHR can be applied to specific contexts. As such, specification recognises pluralism in local contexts without accepting claims of relativism regarding morality and political theory. As a part of this process of specification, these targeted bioethics declarations should explicitly link themselves to the cultural and religious traditions of such groups. There are several advantages to doing so. First, as Nie Jing-Bao (2005) points out, linking the principles of the UDBHR specifically to non-Western cultures helps to defuse the concern that the principles stated in the UDBHR reflect typically Western ethical norms. A demonstration that these principles can be specified to, and supported in, nonWestern contexts is extremely important to the legitimacy and claims of universality of this declaration. Showing the plurality of specifications of the UDBHR principles helps to counter proponents of cultural relativism and, as Nie argues, additional supporting arguments for universalism can be found in non-Western traditions such as Confucianism and Daosim (Nie 2005, 255–256). Furthermore, we can view this process of local specification as bidirectional, with the UDBHR providing content that is locally specified but ideally remaining open to refinement and revision, given continued reflection and operation in the pluralistic cultures and regions in which it applies. For example, local specifications of autonomy that include a core value of community consultation and inclusiveness might serve to inform and provide more detail on the appearance of that value in the UDBHR. Finally, these smaller declarations of bioethical principles can help to build both consensus and legitimacy around universal bioethics values and norms as articulated in universal bioethics declarations. By establishing that the general principles of the UDBHR can be specified to local cultures and contexts successfully, these applications would help demonstrate the universalizability of these principles, whilst embracing pluralism. Moreover, the development of local specifications of the UDBHR would likely have an important practical effect of contributing to political support for and practical implementation of this declaration. These targeted declarations would have the appeal of encouraging action by specific states and communities to demonstrate the relevance of the UDBHR to their context and defuse concerns that it is a neocolonial or Western imposition on their cultures by a distant UN bureaucracy. Since the creation of these targeted documents would necessarily include participation by a wider range of local political leaders, policymakers, health experts, bioethicists, cultural leaders, community members, and patient advocates, the process of developing these specifications would have the added benefit of further strengthening the legitimacy of both the targeted documents and UDBHR by demonstrating the inclusivity of the latter’s development and continued refinement. Where these targeted documents could be given the strength

Politics of Global Bioethical Frameworks   697 of law and linked explicitly to the UDBHR, they have an important ability to make it much more practical without requiring that it be granted the power to enforce its principles on signatory states.

References Andorno, Roberto. 2007. ‘Global Bioethics at UNESCO: In Defence of the “Universal Declaration on Bioethics and Human Rights”.’ Journal of Medical Ethics 33 (3): 150–154. Andorno, Roberto. 2009. ‘Human Dignity and Human Rights as a Common Ground for a Global Bioethics.’ Journal of Medicine and Philosophy 34 (3): 223–240. doi:10.1093/jmp /jhp023. Annas, George, and Michael Grodin. 2008. ‘The Nuremberg Code.’ In The Oxford Textbook of Clinical Research, edited by Ezekiel Emanuel et al., 136–140. Oxford: Oxford University Press. Ashcroft, Richard. 2008. ‘The Declaration of Helsinki.’ In The Oxford Textbook of Clinical Research, edited by Ezekiel Emanuel et al., 141–148. Oxford: Oxford University Press. Benatar, David. 2005. ‘The Trouble with Universal Declarations.’ Developing World Bioethics 5 (3): 220–224. doi:10.1111/j.1471-8847.2005.00119.x. Council for International Organizations of Medical Sciences (CIOMS). 2002. ‘International Ethical Guidelines for Biomedical Research Involving Humans.’ http://www.cioms.ch /publications/guidelines/guidelines_nov_2002_blurb.htm. Council for International Organizations of Medical Sciences (CIOMS). 2016. ‘International Ethical Guidelines for Biomedical Research Involving Humans.’ http://cioms.ch/ethicalguidelines-2016/WEB-CIOMS-EthicalGuidelines.pdf. Donnelly, Jack. 2013. Universal Human Rights in Theory and Practice. 3rd ed. Ithaca, NY: Cornell University Press. Langlois, Adele. 2011. ‘The Global Governance of Bioethics: Negotiating UNESCO’s “Universal Declaration on Bioethics and Human Rights” (2005).’ Global Health Governance 5 (1): 1–23. Macpherson, Cheryl Cox. 2007. ‘Global Bioethics: Did the ”Universal Declaration on Bioethics and Human Rights” Miss the Boat?’ Journal of Medical Ethics 33: 588–590. doi:10.1136 /jme.2005.013797. Nie, Jing-Bao. 2005. ‘Cultural Values Embodying Universal Norms: A Critique of a Popular Assumption about Cultures and Human Rights.’ Developing World Bioethics 5 (3): 251–257. doi:10.1111/j.1471-8847.2005.00123.x. Revel, Michel. 2009. ‘Respect for cultural diversity and pluralism.’ In The UNESCO Universal Declaration on Bioethics and Human Rights Background, Principles and Application, edited by Henk  A.  M.  J.  ten Have and Michèle S.  Jean. Paris, France: UNESCO Publishing. http://unesdoc.unesco.org/images/0017/001798/179844e.pdf. Snead, O.  Carter. 2009. ‘Bioethics and Self-Governance: The Lessons of the “Universal Declaration on Bioethics and Human Rights”.’ Journal of Medicine and Philosophy 34 (3): 204–222. Stanton-Jean, Michèle. 2016. ‘The UNESCO Universal Declarations: Paperwork or Added Value to the International Conversation on Bioethics? The Example of the “Universal Declaration on Bioethics and Human Rights”.’ In Global Bioethics: The Impact of the UNESCO International Bioethics Committee, edited by Alireza Bagheri, Jonathan D. Moreno, and Stefano Semplici, 13–21. New York: Springer International Publishing.

698   Diego S. Silva and Jeremy Snyder ten Have, Henk. 2016. ‘Globalizing Bioethics Through, Beyond, and Despite Governments.’ In Global Bioethics: The Impact of the UNESCO International Bioethics Committee, edited by Alireza Bagheri, Jonathan  D.  Moreno, and Stefano Semplici, 1–12. New York: Springer International Publishing. Trotter, Griffin. 2009. ‘The UNESCO Declaration on Bioethics and Human Rights: A Canon for the Ages?’ Journal of Medicine and Philosophy 34 (3): 195–203. doi:10.1093/jmp/jhp025. UN General Assembly. 1948. Resolution 217.A, ‘Universal Declaration of Human Rights,’ December 10. http://www.un.org/en/universal-declaration-human-rights/. UNESCO. 2005. General Conference, 33rd Session. ‘Records of the General Conference, Paris, 3-21October, 2005, vol. 1. http://unesdoc.unesco.org/images/0014/001428/142825e.pdf. World Medical Association (WMA). 2006. ‘Declaration of Geneva, the 173rd WMA Council Session.’ Divonne-les-Bains, France, May. http://www.wma.net/en/30publications /10policies/g1/.

Index

Note: Figures, tables and boxes are indicated by an italic “f ”, “t” and “b” and notes are indicated by “n” following the page numbers.

A

abortion  28–29, 53 access to medications  605–22 actors involved in  615–17 antiretrovirals  108, 271, 303, 330–33, 613–16 antivirals  6, 89, 91, 541 barriers to  111, 396 global health initiatives for  607–8 global politics of  605–6, 612–22 history of concerns regarding  608–10 human rights and  4, 42, 544 importance of  606–7 innovation and  610–12, 618–19 intellectual property protection and  47–48, 287–88, 396 for NCDs  646 vaccinations  42, 188, 397, 536, 544–45, 607 Ackland, M.  647 Adger, W. Neil  153 administrative capacity of states  147 adolescents. See children and adolescents Adorno, Theodor  91 Advocacy Coalition Framework (ACF)  335, 338 Afghanistan, tailgate medicine in  208–10 Africa decolonization in  553 development assistance for  108, 308, 309, 313, 319n1 Ebola in. See Ebola virus disease health inequality in  59 influenza pandemics in  532 pharmaceutical sector in  311, 312 third world movements in  25 tobacco markets in  663 vaccination campaigns in  587

agency forms of power  61, 65, 71–73 agenda setting  325–38 actors involved in  326–28 ascendance of issues in  334, 633–34 BRICS countries in  306, 317, 318 exclusionary practices in  69 future research needs  336–38 gender issues and  249–51, 253–54 in global health diplomacy  113 health security and  173 ideas in  328–30 institutional influences on  332–33 interests in  330–32 models for  335, 337–38 at national and subnational levels  335 for NCDs  328, 632 overview 325–26 WHO as venue for  303 Aginam, Obijiofor  389, 569 aging populations. See elderly populations Agreement on the Application of Sanitary and Phytosanitary Measures (SPS Agreement)  428, 434 Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) advocacy groups on  356, 396, 610 affordability of medications and  434 BRICS countries’ negotiations on  111, 304, 306, 307 commodification of innovation through 452–53 cross-retaliation principle in  455 disadvantages for low-income countries  72, 360, 504 Doha Declaration and  333, 360, 475 on generic medications  48, 271, 333, 353, 360, 475, 559

700   index AIDS. See HIV/AIDS AIIB (Asian Infrastructure Investment Bank)  10, 304–5 alcohol use collective action for regulation of  391–92 cost of interventions for reduction of 632 deaths resulting from  391 gender differences in  241–43 in global health policy agenda  328 Global Strategy to Reduce the Harmful use of Alcohol  112b, 391 as NCD risk factor  629–31 promotion of responsible drinking  395 Alexander the Great  198 Allen, Luke N.  634, 647 Alma-Ata Declaration (1978) as application of basic needs approach to health 449 economic affordability and  249 on human right to health  505 ideational legacy of  48 on new international economic order  505–6, 591 on primary healthcare  30, 44–47, 51, 224–25, 315, 329, 371 Amorim, Celso Nunes  669 AMR. See antimicrobial resistance Amsden, Alice  596 Annan, Kofi  145–46, 326, 560, 670 anthrax  6, 129, 130, 164, 182, 614 anthropology analytical contributions of  479–80 conceptualizations of power in  62–64, 73 critical thinking in  89 in global health politics  7 medical  62, 63, 73, 353 militant 480 research methodology in  63–64, 75 antiglobalism  39, 53, 379 antimicrobial resistance (AMR) from antibiotic overuse  131, 268 defined 130 governance of  273–74 pharmaceutical intervention and  5 R&D for  619, 621 as security threat  130–32, 134

antiretroviral therapies (ARTs) access to  108, 271, 303, 330–33, 613–16 anticolonial views of  97 in BRICS countries  111, 307, 311 collective responsibility of international community for  500 as preventive therapy  562 prices for  xiii, 475, 559, 613–15 production centers for  311 (RED) project for  413–14, 417 right to health and  502 antiviral medications access to  6, 89, 91, 541 conflicts of interest in recommendation of 357 recognition of utility of  534 stockpiling of  130, 536, 539 apartheid  369, 553, 569–70 Appau, Adriana  399 Aristotle 245 Armbrister, Adria  70 ARTs. See antiretroviral therapies Asia bubonic plague in  21 influenza pandemics in  533, 534 SARS in. See severe acute respiratory syndrome state-led global integration in  47 third world movements in  25 tobacco markets in  663 vaccination campaigns in  587 Asian flu pandemic (1957)  533, 541 Asian Infrastructure Investment Bank (AIIB)  10, 304–5 Assunta, Mary  669, 672 Attaei, Marjan, 646 authority, sources of  275, 349 Avant, Deborah D.  275 avian influenza (H5N1/H7N9)  128, 155, 184–85, 188, 535–37 Aylward, Bruce  207

B

Bacillus Calmette-Guérin (BCG) vaccine 585–88 Baker, Michael G.  516 Ban Ki-Moon  226, 228, 327

index   701 Bankoff, Gregory  126 Barnard, David  504 Barnett, Jon  153 Barnett, Michael  349–50 Barnett, Tony  558 Barnett-Duvall typology  74–75 Bashford, Alison  125 BAT. See British American Tobacco Baumgartner, Frank R.  338 BCG (Bacillus Calmette-Guérin) vaccine 585–88 Béhague, Dominique P.  329 Beltrán-Sánchez, Hiram  242 Benatar, Solomon R.  268, 271, 400, 445, 693 Bendavid, Eran  114 Bergh, Kristofer  113 Bero, Lisa  398 Berry, Christine  400 Bettcher, Douglas  667 Bhattacharya, Jayanta  114 Bhopal industrial disaster (1984)  169 biases. See discrimination; stigma Bill and Melinda Gates Foundation (BMGF) Anti-Tobacco Trade Litigation Fund  437 on cause-related marketing  375 criticisms of  417–21 emergence of  112, 218, 270, 373, 409 functions of  325 funding for  225, 274, 412 GAVI Alliance sponsorship by  594 global health agenda of  53, 411–16 home base for  50 on influenza pandemic preparedness 538–39 tobacco control funding from  674 in transnational state  290 BINGOs (business-interest NGOs)  368, 377 biodefense  180–83, 191–92 bioethics. See Universal Declaration on Bioethics and Human Rights biological weapons. See also bioterrorism anthrax  6, 129, 130, 164, 182, 614 process for wielding  181 proliferation of  110, 180 Soviet program for  130 state-centric approach to  315 biopower 95–96

biosecurity 179–92 as biodefense  180–83, 191–92 as border security  189–92 censorship and  185, 192 defined 179–80 global health risks from  183, 185–86, 191–92 as health security  186–89 as information security  183–86, 192 security dilemmas in  181, 183 bioterrorism agenda setting for  331 anthrax letters as  6, 129, 130, 164, 614 fears regarding  6, 110 preparedness planning for  132, 133 as security threat  103, 129–30, 132 bird flu. See avian influenza Birn, Anne-Emmanuelle  507 birth control  27–28, 397–98 Black, Robert E.  421 Blair, Tony  5, 47, 267 Blindspot (Keshavjee)  222 Bloomberg, Michael  4, 647, 674 Bloomberg Philanthropies  437, 674, 677 Blume, Stuart  583 BMGF. See Bill and Melinda Gates Foundation Bonita, Ruth  640 Bono  273, 414 Booth, Ken  164 border-based biosecurity  189–92 Bourdieu, Pierre  72 Bracht, Caroline  305 brain drain  38, 46, 52 Brazil. See also BRICS countries bubonic plague in  21 civil-military relations in  202 conditional cash transfer programs in  285, 315 development assistance from  303, 308, 310, 311 on FCTC  669, 673 global health diplomacy by  108, 111, 306 pharmaceutical sector in  311, 614 Zika virus in  166, 201–3 breastfeeding  30, 31, 49, 450 breast-milk substitutes  31, 356, 392

702   index Brexit  10, 441, 563 Bricknell, Martin C. M.  209 BRICS countries  301–19. See also Brazil; China; India; Russia; South Africa competing visions of  312 development assistance from  303, 308–13, 318 domestic health models of  307, 315–17 emergence of  42, 301 engagement with global health ­governance  302–7, 311, 317–19 global health diplomacy by  303, 306, 318 health challenges in  301–2, 309 institutional influence of  302, 305–8 material capabilities of  308–11 NCDs in  630 pharmaceutical sector in  311–12, 318, 597 state-centric approaches by  313–15, 319 venues for engagement by  303–5 British American Tobacco (BAT)  394, 395, 434, 663, 667–73, 676–77 Brown, E. Richard  418 Brundtland, Gro Harlem background of  34 on disease and globalization  268 on enlightened self-interest  579 on investments in health  51 on partnerships  396, 518 promotion of global health issues  93, 272 on provision of services  562 tobacco control initiatives of  666, 670 travel restrictions issued by  351 Bryant, Toba  65 bubonic plague biodefense activities involving  182 International Health Regulations on  25 quarantines for  126, 135 as re-emerging disease  32 societal instability and  152 transmission of  21 Buffett, Warren  225, 274, 412 Bump, Jesse B.  329 bureaucratic culture theory  349–50 Busby, Josh  331 Buse, Kent  237, 302, 310 Bush, George W.  108, 270, 560 business-interest NGOs (BINGOs)  368, 377

business sector  387–403. See also public-private partnerships collective action to regulate health-harming industries  390–93 contributions to public interest  393–98 defined 388–89 in global health governance  398–400 overview 387–88 role in global health politics  401–3 types of organizations in  388b Butler, Judith  168 Buzan, Barry  145, 146, 149

C

Cabrera, Oscar  643 Callahan, Daniel  571 Calmette, Albert  585 Cameron, Edwin  559 cancer medications  618 Candau, Marcolino Gomes  25, 26, 589 capabilities approach  70, 145, 154 capacity-based authority  275 capitalism alternatives to  447 cause-related marketing and  375 climate change and  229 critiques of  67, 87, 90–92 environmental degradation due to  222–23 exploitation under  24, 219 globalization and  38, 45, 49, 52 Great Transformation to  217, 219–20 late stage  390 neo-liberal  266, 271 philanthrocapitalism  94, 377, 416 population growth and  27, 28 power differentials in  65 private interest groups and  368 regulatory 642 Capitalocene 222 Caribbean Community (CARICOM)  xiii, 634 Carnegie, Andrew  410 Cash, Richard  136 Casswell, Sally  391 Castells, Manuel  379 cause-related marketing  375 CCT (conditional cash transfer) ­programs  285, 315

index   703 CEA (cost-effectiveness analysis)  115, 451 celebrity diplomacy  414 censorship  185, 192 Centers for Disease Control and Prevention (CDC) bioterror preparedness by  130 disease eradication efforts  594, 596 on Ebola outbreak  265, 352 on HIV/AIDS emergence  553 influenza sample testing by  538 tobacco control efforts  631, 674 CEPI (Coalition for Epidemic Preparedness Innovations) 539 CETA. See Comprehensive Economic and Trade Agreement Chagas, Luiz Carlos  306 Chan, Jennifer  272 Chan, Margaret on access to medications  605 on alcohol industry  392 avian influenza outbreak response by  535 on BRICS countries  301 critique of globalization by  48 cross-border outbreaks under  519 Ebola outbreak response by  190, 273 on global health actors  270 on outbreak reporting  522, 523 on universal health coverage  315 Chan, Priscilla  413 Chandhoke, Neera  372 Chang, Ha-Joon  220 Chan Zuckerberg Initiative  413 Chapman, Audrey R.  502 Chapman, Simon  669, 672 Chen, Ingfei  412 Chernomas, Robert  64–65 CHGA (Commission on HIV/AIDS and Governance in Africa)  560 chikungunya 166 children and adolescents. See also United Nations Children’s Fund in conflict areas  153, 157 Convention on the Rights of the Child  494, 644 GOBI interventions for  30–31, 49 marketing of food and beverages to  115, 633

mortality rates for  59, 109, 152, 221, 227 in poverty  153 Task Force for Child Survival  592, 595 Children’s Vaccine Initiative (CVI)  593–94 China. See also BRICS countries Belt and Road initiative in  305 development assistance from  108, 308–11, 313, 319n1 economic and political rise of  10, 227, 434–35 on FCTC  669 influenza pandemics in  533, 534 life expectancy in  316 military assistance from  204 pharmaceutical sector in  312 population control in  28 primary healthcare in  30, 44, 316, 449 R&D investment by  621 SARS outbreak in  128, 136, 307, 351, 516, 518 state-centric approach in  314–15 Chisholm, Brock  24 cholera failure to detect outbreaks  517 International Health Regulations on  25 quarantines for  20, 21, 126 as re-emerging disease  32, 88 societal instability and  151–52 spread by UN peacekeepers  356, 357 transmission of  20, 21 Chorev, Nitsan  51, 350 Chowdhury, A.  284 cigarettes. See tobacco use CIOMS (Council for International Organizations of Medical Sciences) 688–89 Cipla 613–14 civil liberties  134–35, 138, 146, 163, 167, 379 civil-military cooperation  199–201, 205–8 civil rights  494–95, 497–501 civil society organizations (CSOs)  367–80 on access to medications  333, 616 as actors in global health politics  4, 6, 427 in agenda setting  328, 332 categorization of  372–73, 377 change efforts of  356 conceptualization of  367–69 corporate capture of  375–76

704   index civil society organizations (CSOs) (Continued ) digital technology and  379 diversity of  368, 372, 377 exclusion of participation by  315 in global health governance  373–74, 378 HIV/AIDS activism by  565 human rights as leverage for  508 mobilization against trade agreements  436, 439, 441 overview 367 political nature of  368–69, 637 primary healthcare promotion by  371–72 as tobacco control advocates  670 transnational  290, 356, 372 climate change capitalism and  229 in emerging and re-emerging diseases  33 global health impacts of  223 globalization and  6, 222–23 Intergovernmental Panel on  223 mitigation strategies  379 NCD-informed policies and  645 organizational change in response to  354 skepticism regarding  97 Sustainable Development Goals on  228 Clinton, Bill  47, 557 Coalition for Epidemic Preparedness Innovations (CEPI)  539 Coburn, David  65 Coca-Cola Company  397, 402 Cold War  24–25, 87, 106, 497, 554, 588 collective violence  151 Collins, Pamela Y.  70 Collishaw, Neil  664 colonialism economic development and  220 Enlightenment and  86–87 health policies during  20, 43, 49 tropical medicine and  20, 44, 125–26, 171, 199 Commission on HIV/AIDS and Governance in Africa (CHGA)  560 Commission on Human Security  147, 149–56, 158n1 Commission on the Status of Women (CSW)  238, 247 common security. See human security

communicable diseases agenda setting for  331 early detection and surveillance  4, 513 globalization and  268, 270 in refugee camps  151 regulations to prevent spread of  267 soft power tools for control of  114 communism  25, 28, 91 Communist Manifesto (Marx)  229 companies, defined  388b Comprehensive Economic and Trade Agreement (CETA)  107, 399, 435, 439, 440 compulsory licensing  504, 559, 613–15, 617 compulsory power  74 conditional cash transfer (CCT) ­programs  285, 315 confidentiality  32, 357, 514, 523 conflictual power  72 Connell, Raewyn  251, 252 consent, informed  198 constructivism  113, 349, 493–94, 500 consumer-driven philanthropy  413–14 contraception  27–28, 397–98 Convention on the Rights of the Child  494, 644 Cooper, Andrew F.  414 copyrights 353 Cornwall, Andrea  250 corporate social responsibility (CSR) 395–98 corporations, defined  388b. See also ­transnational corporations corruption 9–10 Cortell, Andrew P.  351 cosmopolitanism 113–14 Costa e Silva, Vera Luiza da  669, 673 Costa-Font, Joan  402 cost-effectiveness analysis (CEA)  115, 451 Costello, Andrew  223 Council for International Organizations of Medical Sciences (CIOMS)  688–89 Courtenay, Will H.  242, 244 Coutinho, Alex  553–54 Cox, Robert  8, 302 Crenshaw, Kimberlé  68, 240–41 critical race theory (CRT)  67–68, 90

index   705 critical security studies (CSS)  161–73 defined 163 emergence of  161, 162 global health politics and  170–73 on health security  164–70, 173 overview 161–62 politics of security and  162–64 on risk-based mentality  165–66 “security as emancipation” approach in  164, 168, 173 theoretical approaches to  163 vulnerability in  168–70, 173 critical theory critical race theory  67–68, 90 criticisms of  96–97 defined 91 of economics  90 Frankfurt School on  91, 97, 162 intersectionality in  68–70, 73 on neo-liberal globalization  92 on philanthropic giving  94 securitization theory  94–95, 134, 163–65 critical thinking  85–98 as academic activity  96–97 on biopower  95–96 in Enlightenment  86–87, 89, 90 epidemiological events and  89 in epistemic communities  89–90 on neo-liberalism  92 overview 85 on political economy  91–93 on (RED) project  93–94 on representation  94–95, 165 social movements and  90, 97 stakes of  98 varieties of  90–91 Critique of Pure Reason (Kant)  86 cross-retaliation principle  455 CRT (critical race theory)  67–68, 90 CSOs. See civil society organizations CSR (corporate social responsibility)  395–98 CSS. See critical security studies CSW (Commission on the Status of Women)  238, 247 Cuba HIV/AIDS quarantines in  135 independence from Spain  21

medical assistance programs  87, 108 primary healthcare in  44 Cueto, Marcos  19 cultural diversity, UDBHR on  690–94 cultural relativism  687, 692, 696 cultural rights. See International Covenant on Economic, Social, and Cultural Rights culture for health  552 Cunningim, Merrimon  417 CVI (Children’s Vaccine Initiative)  593–94

D

Dahl, Robert A.  61 DALYs. See disability adjusted life years Danzon, Patricia M.  415 Davies, Sally C.  131, 552 Davies, Sara E.  513 DDD (digital disease detection)  514, 517, 524 DDT (dichlorodiphenyltrichloroethane)  26, 350, 361n2, 419 Deaton, Angus  552 de Beauvoir, Simone  237 De Bengy Puyvallé, Antoine  374 debt crises  38, 45–46, 88, 288, 471 DeLaet, Debra  187 delegated authority  275 dengue fever  32, 155, 166 de Quadros, Ciro  595 Desai, Sapna  64 descriptive approach to human rights  494, 495, 503–7 determinants of health commercial 677 gender  240–41, 250–53 globalization effects on  6, 40 political 62 social. See social determinants of health upstream 111 development assistance access to medications and  607 altruistic motivations for  287 from BRICS countries  303, 308–13, 318 from developing countries  225 exertion of power through  74 in foreign policy  109 for HIV/AIDS  286–87 impact on health expenditures  226, 283

706   index development assistance (Continued ) for NCDs  287, 627 NGO-isation 372 official  92, 224, 288 philanthropic 411–13 South-South partnerships  111, 313 state-centric approach to  314–15 strategic use of  107–8 Devlin, Stephen  400 dichlorodiphenyltrichloroethane (DDT)  26, 350, 361n2, 419 digital disease detection (DDD)  514, 517, 524 diphtheria  32, 584–85 diplomacy. See global health diplomacy disability adjusted life years (DALYs)  50–51, 309, 454, 629, 630 discrimination. See also stigma gender 70 intersectionality and  69 racism  63, 67 in trade barriers  430, 431 diseases burden of. See global burden of disease communicable. See communicable diseases epidemics. See epidemics globalization and  125, 128, 171, 268, 270, 592–96 infectious. See infectious diseases insecurity and  125–27 lifestyle  154, 156, 664 NCDs. See non-communicable diseases poverty and  154 reporting. See outbreak reporting social and economic impact of  125, 128, 132 tropical. See neglected tropical diseases vulnerability to  33, 39, 126, 128, 173 zoonotic  127, 532, 551, 554, 572 dispositional power  72 dispute settlement mechanisms  399, 429–37, 440, 455, 477 DNDI (Drugs for Neglected Diseases Initiative) 572 Doctors without Borders. See Médecins sans Frontières Dodds, Susan  169, 170 Doha Declaration (2001)  333, 360, 475, 614–15

Doll, Richard  661 Dollar, David  221 domestic resource mobilization (DRM)  507 Doughnut Economics (Raworth)  223 Dow Chemical  400 Drèze, Jean  282 drugs. See medications Drugs for Neglected Diseases Initiative (DNDI) 572 Dry, Sarah  269 Duncan, Thomas Eric  123, 124, 137 dysentery 198

E

EBM (evidence-based medicine)  245, 329, 541–43, 545 Ebola virus disease (EVD) agenda setting for  331, 334 border-based biosecurity response to 190–92 containment strategies  135, 155 economic impact of  155 medical personnel assistance with  108, 190 military assistance with  201, 204–6 mortality rates  204 outbreak reporting  514, 515, 517, 520 PHEIC declaration for  166, 190 public fears regarding  123–24 as security threat  103, 124, 128, 165 societal instability from  152, 154, 157 structural adjustment programs and  472–73 travel and trade restrictions for  136–37, 190–91, 331 treatments for  312, 313 WHO response to outbreak  9, 265, 275, 359 e-cigarettes  394–95, 642 economic globalization consolidation of ownership in  388 disease eradication and  592–96 material breakdown of markets in  48 neo-liberal ideology and  65 organizational change in response to  354 tobacco industry and  663 trickle down effect of  221 economic growth and development in colonial era  220 core values of  450

index   707 gender inequality and  152 global health and  3, 50, 218 in Great Transformation  217, 219–20 improvement projects for  87–88 international health and  19, 26, 34 lifestyle diseases and  156 market civilization model of  271 neo-liberal views of  46–47 population control in  27 state capacity and  147, 148 trade liberalization for  446 economic inequality  284, 370, 390, 478 economic rights. See International Covenant on Economic, Social, and Cultural Rights ECOSOC (United Nations Economic and Social Council)  238, 247, 639 Eide, Asbjorn  500 Eisenberg, Pablo  417 Elbe, Stefan  126, 131–33, 165 elderly populations  153–54, 157, 329 electronic nicotine delivery systems (ENDS)  394–95, 642 Emanuel, Ezekiel J.  562, 563 emerging infectious diseases (EIDs) characteristics of  32–33 global surveillance of  91, 133 lack of response to  88 threats posed by  127–28, 133, 535, 543 zoonotic 127 Enemark, Christian  179 Engels, Friedrich  219 Enlightenment  86–87, 89–91, 95, 97 EPI (Expanded Programme on Immunisation)  590–92, 597, 599 epidemics. See also pandemics blame of foreigners for  20 chronic  155, 156 as drivers of innovation  89 industrial  390–91, 477, 632 politics of response  91 societal instability during  151–52 sudden-onset 155–56 epistemic power  72 Essential Medicines List  608–10, 615 ethical relativism  687 ethnography  63–64, 70, 73, 353

Europe and European Union beef import dispute  434 Better Regulation initiative in  400 Enlightenment in  86–87 Great Divergence with settler colonies  217, 219–20 Great Transformation in  217, 219–20 health inequality in  59 human development indicators for  230 influenza pandemics in  532, 534 Marshall Plan for  224 on medication pricing  620 social movements in  368 tobacco markets in  663 tobacco use patterns in  241 trade agreement ratification in  440 vaccination campaigns in  586–87, 598 EVD. See Ebola virus disease evidence-based medicine (EBM)  245, 329, 541–43, 545 Expanded Programme on Immunisation (EPI)  590–92, 597, 599 expert authority  275 Exxon Mobil Malaria Initiative  395

F

Falk, Richard  570 family-planning programs  27–29, 356 Family Smoking Prevention and Tobacco Control Act of 2009  429–30, 432 Fanon, Frantz  87 Farley, John  410 Farmer, Paul  47, 88, 480 Faude, Benjamin  359–60 FCTC. See Framework Convention on Tobacco Control FDA (Food and Drug Administration)  27, 415, 429–32 Feachem, Richard  470 Feigl, Andrea B.  647 Felski, Rita  96–97 females. See gender; women Fenner, Frank  594 FENSA (Framework for Engagement with Non-State Actors)  375 Fidler, David  7, 90–91, 106, 112, 133–34, 269, 287, 516, 521–22

708   index Figuié, Muriel  114 Finlay, Carlos  21 Finnemore, Martha  275, 349–50 firms, defined  388b Fleming, Alexander  552 flu. See influenza focusing events  113 Foege, William  592, 595 Food and Drug Administration (FDA)  27, 415, 429–32 food industry  392–95, 476–77, 629–30, 637, 644 foreign military assistance (FMA)  201, 204–6 foreign policy. See also international relations of donor nations  26 health in relation to  105–14 hierarchy of functions of  106, 106f on population control  28 soft power in  111 for-profit organizations. See business sector Forsythe, David P.  499 Foucault, Michel  95–96 Fouchier, Ron  184–85, 520 Foundation for a Smoke-free World  642, 676 Fowler, Norman  555 Framework Convention on Tobacco Control (FCTC) alliance-building in support of  668–71 evidence base for  667–68 in global health diplomacy  672 in human rights framework  643–44 on illicit tobacco trade  675–76 implementation of  673–74, 677 as international agreement  103, 112b leveraging of interests in  332 mobilizing political support for  665–67 negotiations on  111, 306, 328, 332 nonbinding nature of  633 opposition to  307, 376, 668–74 on protection of public health  391, 631 on tobacco industry interference in health policy 394 Framework for Engagement with Non-State Actors (FENSA)  375 Frankfurt School  91, 97, 162 Freire, Paulo  552, 565n2

French Declaration of the Rights of Man and of the Citizen (1789)  495 Frerichs, Ralph R.  357 Frerks, Georg  199 Freud, Sigmund  96 Friedman, Milton  220, 221, 230 Frist, Bill  130 Fuchs, Doris  411 Fukuda, Keiji  522 Fukuda-Parr, Sakiko  147 Fund for Research in Neglected Tropical Diseases (FRiND)  573 Furst, Thomas  571

G

Gafton, Joseph  367 Gagnon, Michelle L.  112 Gallagher, Allen  676 Galtung, Johan  268, 480 Garrett, Laurie  6, 88 Gates, Bill and Melinda  4, 49–50, 225, 273, 412, 597. See also Bill and Melinda Gates Foundation GATS (General Agreement on Trade in Services)  428, 434, 452 GATT (General Agreement on Tariffs and Trade)  428–29, 433, 474, 610 GAVI. See Global Alliance for Vaccines and Immunizations gay populations. See homosexuality GBD. See global burden of disease GBH (greedy bastards hypothesis)  67 GCM/NCD (Global Coordinating Mechanism for Noncommunicable Diseases)  639, 640 gender 237–54. See also gender inequality conceptual framework for health and  240–46, 240f defined 238 as determinant of health  240–41, 250–53 discrimination based on  70 global burden of disease and  239, 253 in global health agenda  249–51, 253–54 health behaviors and  241–44 HIV/AIDS and  562 in international development  250 life expectancy and  237–39, 250, 251, 253

index   709 sex vs.  238–40 as social construct  237, 238, 253 transgender populations  66, 240, 252 utilization of health services by  243–45 gender blindness  246, 252–54 gender inequality absence of effective response to  251–52 economic development and  152 health effects of  238, 239, 243–46 in health workforce  246 organizational responses to  247–49 poverty and  152 structural vulnerability and  63 gender mainstreaming  248, 250 gender roles modernization hypothesis 242 General Agreement on Tariffs and Trade (GATT)  428–29, 433, 474, 610 General Agreement on Trade in Services (GATS)  428, 434, 452 General Assembly. See United Nations General Assembly generalism, defined  687 generic medications active pharmaceutical ingredients for  312 compulsory licensing for  504, 559, 613–15, 617 Doha Declaration on  614–15 expenditures on  607 production centers for  311 Revised Drug Strategy on  610 TRIPS on  48, 271, 333, 353, 360, 475, 559 Geneva Declaration (1948)  688 genocide  153, 499 German, Danielle  66 GFATM. See Global Fund to Fight AIDS, Tuberculosis and Malaria GHD. See global health diplomacy GHG. See global health governance GHSI (Global Health Security Initiative)  134, 517 Gill, Bates  113 Gill, Stephen  268, 271, 400, 445 Gilmore, Anna  676 Gilson, Lucy  90, 112 GISN (Global Influenza Surveillance Network)  188, 533, 534, 536

GISRS (Global Influenza Surveillance and Response System)  536–37, 539 GlaxoSmithKline 395 Gleneagles Declaration (2005)  5 Global Action Plan for Influenza Vaccines 537 Global Action Plan for the Prevention and Control of Non-communicable Diseases  393, 635 Global Alliance for Vaccines and Immunizations (GAVI) as actor in global health politics  4, 271 in agenda setting  331 establishment of  50, 594, 607 funding for  274, 291, 401 governance structure  358 on results-based financing  51 strategies utilized by  597, 599 global apartheid metaphor  570 global burden of disease (GBD) BRICS countries and  309 corporate influences on  375 gender and  239, 253 measurement of  50, 454 NCDs in  108 Global Coordinating Mechanism for Noncommunicable Diseases (GCM/NCD)  639, 640 Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) as actor in global health politics  218, 270 in agenda setting  331 corruption in fund disbursement  9–10 country coordinating mechanism of 314–15 establishment of  50, 93, 110, 116n2, 134, 286, 503 evaluation of  114 expenditures of  607 funding for  274, 291, 333, 401, 560, 563 generic medication purchases by  615, 616 governance structure  358 negotiation of health issues by  105 (RED) project contributions to  93–94, 413–17 on results-based financing  51

710   index global health agenda setting for. See agenda setting biosecurity as risk to  183, 185–86, 191–92 climate change impact on  223 conditionalities of  46 critical thinking  in. See critical thinking definitions of  3, 38, 41 diplomacy and. See global health diplomacy in economic growth  3, 19, 26, 50 Enlightenment influences on  86, 87 governance of. See global health governance human security and  143–44, 149–57 infectious diseases and  155–56 international development effects on  218, 221–23, 229 international health compared to  104 military and. See military assistance origins of  38, 125, 170, 189 philanthropy and. See philanthropy politics of. See global health politics poverty and  51, 154–55 selectivity in  38, 39, 49–51 violence and  150–54 global health diplomacy (GHD)  103–16 by BRICS countries  303, 306, 318 defined 104–5 drivers of  112–14 evaluation of  114–15 FCTC in  672 future outlook for  115–16 health and foreign policy link in  105–14 instruments of  111–12, 112b nonstate actors in  113 origins of  105 overview 103–4 as soft power tool  110–11, 306 global health governance (GHG)  265–76 architecture of  270–72 authority types in  275 BRICS countries’ engagement with  302–7, 311, 317–19 business sector in  398–400 civil society organizations in  373–74, 378 corporate influence in  375 criticisms of  9–10, 265–66

history of cooperation on  19–21 investment-oriented approach to  49–51 philanthropy in  410, 416, 421–22 politics of  172, 272–76 power distribution in  10, 273–74 rational actor model of  65 reform of structures for  643 risk-based mentality to  165–66 sector-specific 273–74 shifts in  92–93, 165–66, 266–69 vulnerability of norms of  53 global health politics as academic discipline  1–2, 4, 551 of access to medications  605–6, 612–22 actors involved in  4, 33, 270–71 agenda setting in. See agenda setting business sector in. See business sector civil society and. See civil society organizations critical security studies and  170–73 defined 3–4 development of  4–7 of epidemic response  91 future outlook for  9–11 gender in. See gender of globalization. See globalization of healthcare reform. See healthcare reform of inequality. See health inequality interdisciplinary nature of  7–8, 10–11 power in. See power representation in  94–95, 165 states and. See states Global Health Security Initiative (GHSI)  134, 517 Global Influenza Surveillance and Response System (GISRS)  536–37, 539 Global Influenza Surveillance Network (GISN)  188, 533, 534, 536 globalization antiglobalism  39, 53, 379 climate change and  6, 222–23 criticisms of  10, 48, 221, 267 definitions of  37, 39–40, 217, 220, 291 determinants of health and  40, 47, 65 disease and  125, 128, 171, 268, 270, 592–96 economic. See economic globalization food industry and  392–93, 395, 476–77

index   711 health policy agenda and  103 inequality and  220–22 integrative and ideational aspects of  37–42 neo-liberal. See neo-liberal globalization of pharmaceutical sector  5, 622 primary healthcare and  41 privileged position of business in  289 societal effects of  3 trade liberalization and  6, 470 transformationalist approach to  40 waves of  220 global North debt crises triggered by  88 development discourse used by  217 economic shifts in  478 Great Transformation and  219 knowledge production in  89–90 politics of epidemic response in  91 Global Outbreak Alert and Response Network (GOARN)  266, 270, 275, 307 Global Polio Eradication Programme (GPEI) 596 global political economy of health (GPEH)  470, 479–80 Global Programme on AIDS (GPA)  352, 358–59, 556 Global Public Health Information Network (GPHIN) 517–19 global South development assistance for  107 economic shifts in  478 Great Transformation and  219 health security in  42 health surveillance in  42 incentives for investment in  415 international development and  217, 218, 224, 225 postcolonial politics of  41 poverty reduction strategies in  48 South-South partnerships  111, 313 Global Tobacco Surveillance System (GTSS)  631, 674 global warming. See climate change GOARN (Global Outbreak Alert and Response Network)  266, 270, 275, 307 GOBI interventions  30–31, 49, 450 Goehler, Gerhard  72

Goldade, Kathryn  63 good governance  145, 147, 313, 455, 460 Goodin, Robert E.  170 Gore, Al  557 Gostin, Lawrence O.  133, 643 government-organized NGOs (GONGOs) 368 GPA (Global Programme on AIDS)  352, 358–59, 556 GPEH (global political economy of health)  470, 479–80 GPEI (Global Polio Eradication Programme) 596 GPHIN (Global Public Health Information Network) 517–19 Graham, E. R.  352 Gramsci, Antonio  72, 92, 229 Grant, James  31, 49, 326, 506, 595 Graunt, John  237 Great Depression  447 Great Divergence  217, 219–20 Great Transformation  217, 219–20 greedy bastards hypothesis (GBH)  67 Greener, Robert  155 Greer Murphy, Amy  66 Griffin, Jeffrey A.  143 Group of Seven/Eight (G7/G8) Gleneagles Declaration  5 Global Health Security Initiative from  517 health agenda of  105, 134, 272, 286 membership in  116n1, 303–4, 525n2 Muskoka Initiative on Maternal, Newborn and Child Health  108 in transnational state  290 Group of Twenty (G20)  105, 134, 272, 303, 306 GTSS (Global Tobacco Surveillance System)  631, 674 Guérin, Camille  585

H

Habermas, Jürgen  162 HAI (Health Action International)  356, 608–9 Haiti earthquake (2010)  152, 517 Halperin, Sandra  291 Hammonds, Rachel  493 Hankivsky, Olena  241

712   index Hanlon, Gerard  398 Hanrieder, Tine  347, 352, 355 hantavirus 155 hard power  72, 104, 110 Harman, Sophie  271, 421 Harmer, Andrew  217, 302, 304, 310 Hart, Tom  284 Hartzell, Caroline A.  472 Haugaard, Mark  72 Hawkes, Sarah  237 Hawkins, Benjamin  427, 437 Health Action International (HAI)  356, 608–9 health and healthcare in colonial era  20, 43, 49 culture for  552 definitions of  149–50 determinants of. See determinants of health economics of  564 foreign policy in relation to  105–14 global. See global health as human right. See human rights in ideologies of development  87–88 inequality in. See health inequality in neo-liberalism  33, 37, 41, 43, 88 primary. See primary healthcare privatization of  46, 47, 222, 243, 451, 452 reform. See healthcare reform security and. See health security universal. See universal health coverage healthcare reform  445–61 context for contemporary debates on 446–49 neo-liberalism and  450–55, 461 overview 445–46 post-global financial crisis  456–61 primary healthcare in  449–53 socialism and  448–49 universal health coverage in  316 Washington Consensus and  454, 456 Health for All (HFA) movement  445, 449, 591, 608–9 health inequality  59–76 analytical frameworks for  74–75 capabilities approach to  70 cosmopolitanism on  113–14 critical race theory on  67–68

defined 60 determinants of  59, 61 intersectionality and  68–70, 73 literature review  60–61, 70–73 measurement of  60 in mortality rates  59 NCDs and  630–31 political science of  285 power in relation to  62–67, 70–73, 469 in trade agreements  110 health personnel, guidelines for international recruitment of  112b health policy triangle  90, 112 health security  123–38 allocation of resources to  133–34 antimicrobial resistance and  130–32, 134 benefits of securitizing health  132–34 biosecurity practices as  186–89 bioterrorism and  103, 129–30, 132 collaboration with public health actors for 133 construction of threats to  127–32 critical security studies on  164–70, 173 defined 186 disease and insecurity  125–27 Ebola virus and  103, 123–24 emerging infectious diseases and  127–28, 133, 543 global health diplomacy and  113 in global South  42 high politics of  41 HIV/AIDS and  94, 103, 106, 128–29, 133–34, 148–49 human rights and civil liberties issues in 135 human security in relation to  150, 543 in medicalization of security  126, 131–33 opportunity costs of  137–38 political attention on  133–34, 166–67 prioritizing risks and responses for  186–89 responses generated by threats to  132 sacrifices for  134–38 travel and trade restrictions for  136–37, 165, 189–91, 207 vulnerabilities in  167–70 Hearn, Jeff  203 hegemonic power  72

index   713 Hein, Wolfgang  616 Helsinki Declaration (1964)  688 Henderson, Donald  29, 594, 595 hepatitis B  206, 598, 599 hepatitis C  616, 618, 619 Heymann, David  6–7, 188 HFA (Health for All) movement  445, 449, 591, 608–9 H5N1 (avian influenza)  128, 184–85, 188, 535–37 Hickel, Jason  230 high-income countries (HICs) development assistance from  108, 109 healthcare financing in  283 influenza research in  185, 532, 534, 535 intersectionality in  69 military assistance from  200 NCDs in  630 TRIPS rules and  72 vertical campaigns and  26 Hill, Bradford  661 Hindmarsh, Richard  419 historical materialism  66–67 HIV/AIDS 551–65. See also Global Fund to Fight AIDS, Tuberculosis and Malaria advocacy for  268, 272, 565 agenda setting for  329–31, 333, 334 developmental assistance for  286–87 emergence of  32, 88, 551–54, 612–13 epidemiological scenarios for  556–57 funding for  560, 561f, 563–64 gendered nature of  562 global response to  xiii–xiv, 5, 32, 93, 129 governance of  271, 273, 276 human rights and  135, 331, 503–4, 508 innovation resulting from  89 intersectionality and  69, 70 Jaipur paradigm on  558–59 mortality rates  114 politicization of  554, 556, 557, 564–65 poverty and  155, 552, 559 pre-exposure prophylaxis for  562 prevention strategies  555–56, 561–62 public health approach to  552, 554–55 quarantines for  135 Resolution 1308 on  xiii, 110, 271, 557–58 risk mentality towards  165

as security threat  94, 103, 106, 128–29, 133–34, 148–49 stigma associated with  32, 66, 94, 167, 556 treatment for. See antiretroviral therapies Ho, Vivian  416 Hoddie, Matthew  472 Holbrooke, Richard  129 Holden, Chris  427, 437 Holm, Johannes  585 Holmes, Seth M.  63 Holt, Timothy H.  507 homosexuality  32, 503, 553, 555–56, 559, 565 H1N1 (swine flu) emergence of  537–38 as impetus for addressing global health issues 103 monopolization of vaccines for  91, 188 PHEIC declaration for  357 response to  269, 538, 541–42 as security threat  128 travel restrictions for  136, 331 Horkheimer, Max  91, 162 Horton, Richard  39, 41–42, 376 Hoy, Chris  285 H7N9 (avian influenza)  155 Huang, Yanzhong  301, 302 Hudson, Ian  65 humanitarianism budget allocation for  41–42 colonialism justified by  20 development aid as  4 health policy as  103, 106, 579 as improvement project  87 military assistance with  197, 199–201 new humanitarianism  5 human rights  493–508 in agenda setting  329, 330, 333–35 citizens’ rights vs.  495–500, 507–8 civil  494–95, 497–501 claimability condition for  496–98 descriptive approach to  494, 495, 503–7 freedoms vs. entitlements  497, 500–501, 508 gender equality  238 health security and  134–35 HIV/AIDS and  135, 331, 503–4, 508 ICESCR. See International Covenant on Economic, Social, and Cultural Rights

714   index human rights (Continued ) international norms for  494 as leverage for NGOs  501–2, 508 medication access and  4, 42, 544 NCDs and  643 normative approach to  494–502 PAHO on  23 political  494–95, 497–501 in postcolonial society  43–44 UDBHR. See Universal Declaration on Bioethics and Human Rights UDHR. See Universal Declaration of Human Rights WHO on  24, 44 Human Rights in International Relations (Forsythe) 499 human security  143–57 components of  144, 145 global health and  143–44, 149–57 health security in relation to  150, 543 infectious diseases and  155–56 national security in relation to  145–46, 157 overview 143–44 poverty and  152, 154–55 state capacity and  147–49, 148f, 155–57 UN Commission on  147, 149–56, 158n1 UNDP framework for  144–46 violence and  150–54

I

ICAP (International Center for Alcohol Policies) 391–92 ICCPR (International Covenant on Civil and Political Rights)  494–95, 497–501 ICESCR. See International Covenant on Economic, Social, and Cultural Rights ICPD (International Conference on Population and Development)  31, 248, 333, 356 ICRC (International Committee of the Red Cross and Red Crescent)  199 ideational power  4 IFPMA (International Federation of Pharmaceutical Manufacturers Associations)  594, 609–10, 616 IGOs. See intergovernmental organizations IHRs. See International Health Regulations

Illich, Ivan  552, 565n2 IMF. See International Monetary Fund immanent (unintentional) development  217, 218–23, 229 immigrant populations fear-mongering rhetoric targeting  53 framing as health risks  171 multilevel governance for  274 welfare reforms impacting  66 immunizations. See vaccinations Imperial Tobacco  663 income inequality  47, 229, 456 India. See also BRICS countries access to healthcare in  460 agenda setting in  335 bubonic plague in  32, 152 in colonial era  220 development assistance from  303, 308–11, 313 gender inequality in  70, 239, 243 health promotion activities in  66 hysterectomy in  64 implementation of WHO recommendations in 115 influenza pandemics in  533 pharmaceutical sector in  311–12, 597, 613–14 population control in  28, 356 social indicators in  282 state-centric approach in  314 tobacco use patterns in  241 vaccination campaigns in  587–88, 590, 598 Indonesia cigarette flavouring dispute with US 429–33 decentralization in  283 demands for access to vaccines  42, 188, 536, 544 on FCTC  673 tsunami in (2004)  200 industrial epidemics  390–91, 477, 632 inequality economic  284, 370, 390, 478 gender. See gender inequality globalization and  220–22

index   715 health. See health inequality income  47, 229, 456 infectious diseases development assistance for  108 emerging. See emerging infectious diseases global health and  155–56 global surveillance of  91, 133, 187–88 human security and  155–56 poverty and  154 re-emerging  32–33, 88, 535, 543 reporting. See outbreak reporting as security threat  127–28, 179, 543 social and economic impact of  132 social-distancing measures for  132, 135, 190, 542 transboundary risks from  6, 128 travel restrictions in response to  136–37, 189–91 influenza. See also influenza pandemics avian  128, 155, 184–85, 188, 535–37 dispersal of research on  185–86, 532 global surveillance of  187–88, 533, 534, 536, 545 seasonal  532, 534, 540, 541 vaccination for  186, 188–89, 531–41, 544–45 influenza pandemics  531–45 Asian (1957)  533, 541 debates on response mechanisms  89 economic consequences of  542 fears regarding  6, 187, 531, 535–36 governance arrangements for  531, 535, 544, 545 history of  532–34 norms and ideas shaping policy on  539–44 preparedness for  132, 185, 188–89, 306, 535–44 securitization of  543 Spanish (1918)  532, 534, 539–40, 543 swine flu. See H1N1 informed consent  198 Ingram, Alan  8, 85, 286 Institute of Medicine (IoM)  127, 267–68, 535 institutional capacity of states  147, 149 institutional power  72, 74, 355 Intellectual Property Committee (IPC) 396

intellectual property protection. See also Agreement on Trade-Related Aspects of Intellectual Property Rights; patent protections copyright and  353 harmonization of  475 medication access and  47–48, 287–88, 396 as policy tool  617 public goods vs.  573 regulatory conflict over  359–60 transnational network influence on  290 intentional (planned) development  217–18, 224–29 intergovernmental organizations (IGOs) 347–61. See also public-private partnerships on access to medications  617 as actors in global health politics  4, 249 autonomy of  349–52 competition among  358 dynamics of change in  354–60 Ebola outbreak response by  155 global health diplomacy by  105 influence on member states  353–54 interconnectedness of  360, 361 NGOs compared to  347 overview 347–48 power of  348–54 roles and responsibilities of  348–49 Intergovernmental Panel on Climate Change (IPCC) 223 International AIDS Society  4, 270 International Bank for Reconstruction and Development 224 International Center for Alcohol Policies (ICAP) 391–92 International Committee of the Red Cross and Red Crescent (ICRC)  199 International Conference on Population and Development (ICPD)  31, 248, 333, 356 International Conference on Primary Health Care 30 International Covenant on Civil and Political Rights (ICCPR)  494–95, 497–501

716   index International Covenant on Economic, Social, and Cultural Rights (ICESCR)  106, 144, 494, 497–502, 637 international development  217–30 assistance for. See development assistance conceptualizations of  217 contemporary goals of  226–29, 226t, 228t economic. See economic growth and development future outlook for  229–30 gender policies in  250 immanent (unintentional)  217, 218–23, 229 implications for global health  218, 221–23, 229 planned (intentional)  217–18, 224–29 International Ethical Guidelines for Biomedical Research Involving Human Subjects 688 International Federation of Pharmaceutical Manufacturers Associations (IFPMA)  594, 609–10, 616 International Federation of Red Cross Societies 22 international health as academic discipline  25 economic growth and  19, 26, 34 global health compared to  104 goals for  29, 45, 224 origins and evolution of  19, 267 vertical approaches to  44, 49 International Health Regulations (IHRs) compliance with  307 health security and  126, 136, 187 on interference with international traffic and trade  190 legacy of  34 on outbreak reporting  136, 513–16, 522–24 on PHEICs  166, 187 revisions to  103, 113, 134, 306, 348 state-centric approaches to  314 WHO mandate in  25, 351 International Monetary Fund (IMF) bureaucratization and  350 development agenda  225 establishment of  224

good governance lexicon in  455 on influenza pandemic preparedness  535, 538–39 policymaking influences  92 response to debt crises  38, 45–46, 88, 471 structural adjustment programs  38, 46, 221, 353, 371, 471–73 in transnational state  290 International Organization for Standardization (ISO)  398–99 International Organization of Consumer Unions (IOCU)  609 international relations (IR). See also foreign policy critical thinking in  89 in global health politics  7–8 on health security  164–65 high/low politics in  5, 106 human rights in  499 philanthropy and  410 post-positivism in  162 realist theory of  91, 112–13, 493 securitization theory in  94–95, 134 security dilemmas in  181, 183 states as political units of  40 violence as conceptualized in  150 International Sanitary Conferences  20–21, 126, 170, 172, 266, 348, 389 Internet surveillance response programs (ISRPs)  514–19, 521, 523 interpersonal violence  151, 152, 157 intersectionality  68–70, 73, 240–41 investor-state dispute settlement (ISDS)  399, 436–37, 440, 477 IOCU (International Organization of Consumer Unions)  609 IoM (Institute of Medicine)  127, 267–68, 535 IPC (Intellectual Property Committee)  396 IPCC (Intergovernmental Panel on Climate Change) 223 Iqbal, Zaryab  151 IR. See international relations Iraq, tailgate medicine in  208–10 Irwin, Rachel  114, 115 ISDS (investor-state dispute settlement)  399, 436–37, 440, 477

index   717 ISO (International Organization for Standardization) 398–99 isolationist policies  22, 136 ISRPs (Internet surveillance response programs)  514–19, 521, 523 Ivins, Bruce  130 Iyer, Aditi  69, 70

J

Jaggar, Alison M.  247 Jaipur paradigm  558–59 Japan Tobacco International (JTI)  395, 663, 669 Jenkins-Smith, Hank C.  338 Jenner, Edward  583, 584 Johnson, Anne M.  329 Joint United Nations Programme on HIV/ AIDS (UNAIDS) on access to HIV/AIDS treatment xiii, 333 epidemiological scenarios developed by 556–57 establishment of  32, 273, 358–59, 557 expert authority of  275 harassment and bullying within  10 as meta-organization  361n1 political accountability mechanisms and 637 Jones, Bryan D.  338 Joseph, Jonathan  268–69 JTI (Japan Tobacco International)  395, 663, 669 juveniles. See children and adolescents

K

Kaddar, Miloud  600 Kaldor, Mary  368, 379 Kamradt-Scott, Adam  197, 329, 531 Kanavos, Panos  402 Kant, Immanuel  86, 95, 97 Kaposi’s sarcoma  32, 553 Kapstein, Ethan B.  331 Kelsall, Tim  284 Kennedy, Jonathan  217 Kenny, Katherine E.  51 Kerrigan, Deanna  66 Keshavjee, Salman  222

Kevany, Sebastian  114 Keynes, John Maynard and Keynesian economics  230, 447, 448, 456 Khazatzadeh-Mahani, Akram  103 Khrushchev, Nikita  25 Kickbusch, Ilona  7, 106–7, 269, 271 Kim, Jim Young  47 Kingdon, John W.  112, 113, 335, 337 Kirton, John  305 Koblentz, Gregory  180 Koch, Robert  583, 585 Kochi, Arata  418 Koplan, Jeffrey P.  42 KraftHeinz 395 Krause, Keith  162 Krieger, Nancy  469 Kulik, Julia  305

L

Labontè, Ronald  93, 103, 112, 397 Lake, David  471 Lakoff, Andrew  42–43 Lancet Commission  10, 50 Latin America in colonial era  220 conditional cash transfer programs in 285 epidemics in  20–21, 32 pharmaceutical sector in  312 public health services in  88 social movements in  368 tobacco markets in  663 vaccination campaigns in  587 Latour, Bruno  97–98 Lauridsen, Ernst  609 Laws, Edward  295 Leach, Melissa  269 League of Nations Health Organization (LNHO)  22, 23, 34, 348, 586 Lederberg, Joshua  127, 128, 580 Lee, Kelley  1, 106, 109, 114, 164, 306, 387, 661 Lee Jong-wook  518–19 legitimacy, of bioethical frameworks  687–90, 694 Lencucha, Raphael  332 Li, Tanya Murray  87 Liang, Brian A.  643

718   index life expectancy. See also mortality rates cosmopolitanism on differences in  113 gains in  458, 627, 628 gender differences in  237–39, 250, 251, 253 globalization and  221 in Great Transformation  220 neo-liberal policies and  222, 454 socio-economic status and  59, 152 lifestyle diseases  154, 156, 664 Liu, Joanne  273 LNHO. See League of Nations Health Organization Lopez, Ana Mendez  629 Lorber, Judith  238 Lorillard 431 low- and middle-income countries (LMICs) collapse of public health infrastructure in  33 debt crises in  288, 471 development assistance for  109, 619 dispute settlement mechanisms for  433 fiscal burden of foreign debt in  225, 288, 448 food industry in  476 green revolution in  23 healthcare financing in  283 HIV/AIDS funding in  563 influenza research as benefit for  185 intersectionality in  69 military assistance in  200, 208 NCDs in  59, 108, 630 population control in  27–29 primary healthcare in  449, 450, 456 R&D activities in  621 rural hygiene in  22 Sustainable Development Goals for  228 tobacco use in  390–91 TRIPS rules and  72 vaccinations in  536, 537, 598–99 WHO regional offices in  24 Lu, Chunling  283 Lush, Louisiana  327, 331–32

M

MacFarlane, S. Neil  146 Mackenzie, Catriona  169, 170 Mackey, Tim K.  643 Magnusson, Roger  627 Maher, Anthony  633, 634

Mahler, Halfdan medicine policy conference organized by 609 on primary healthcare  30, 31, 44, 49, 608 on vaccination programs  592, 594 on women’s health needs  247–48 malaria. See also Global Fund to Fight AIDS, Tuberculosis and Malaria agenda setting for  328 Alexander the Great and  198 drug-resistant 611 economic benefits of reducing  53 eradication campaigns  26–27, 31, 350, 589, 596 Exxon Mobil Malaria Initiative  395 as re-emerging disease  88 Roll Back Malaria initiative  51 males. See gender Malthus, Thomas  219, 230 Mann, Jonathan  32 Marburg virus  155 maritime sanitation rules  19, 20 Marshall Plan  224 Martin, Emily  171 Marx, Karl and Marxism on capitalism  219 Communist Manifesto 229 critique of political economy in  92 historical materialism in  66–67 on metabolic rift  222 neo-Marxism 65–67 on power relations  65–67 on revolutionary movements  95 Ricoeur on  96 on universal human emancipation  96 material power  4, 62, 73, 355, 402 Matthews, Kirstin R. W.  416 Mbeki, Thabo  558 McCollum, Rosalind  69–70 McCoy, David  367, 420–21 McDonald, Matt  164 McGrady, Benn  439 McInnes, Colin  1, 109, 164, 165, 265, 329 McKee, Martin  186 McMichael, Tony  223 MDGs. See Millennium Development Goals Mead, Walter Russell  478–79 measles  594, 596, 598

index   719 MEDCAPs (Medical Civic Action Programmes)  200, 208–10 Médecins sans Frontières (MSF) as actor in global health politics  4, 33 disease surveillance networks of  517 Drugs for Neglected Diseases Initiative from 572 Ebola outbreak assistance from  204, 205, 265 establishment of  33 opposition to military-humanitarianism  199 principled authority of  275 medical anthropology  62, 63, 73, 353 Medical Civic Action Programmes (MEDCAPs)  200, 208–10 medical/industrial complex  453 medicalization of security  126, 131–33 medications. See also pharmaceutical sector access to. See access to medications antivirals. See antiviral medications ARTs. See antiretroviral therapies Essential Medicines List  608–10, 615 expenditures on  606, 607, 619 generic. See generic medications innovation in  610–12 for neglected tropical diseases  572 patents for. See patent protections penicillin  198, 552 pricing of  47–48, 290, 434 resistance to. See antimicrobial resistance Revised Drug Strategy  609, 610 standardization of  22 stockpiling of  130, 137, 536, 539 vaccines. See vaccinations Medicines Patent Pool (MPP)  616 Mejia, Raul  673 Memish, Zaid  522 men. See gender menstrual hygiene management  331, 332 Merck 578 Messineo, Carol  147 metabolic rift  222 microbicides  562, 565n5 Middle East respiratory syndrome (MERS)  128, 518, 520–24, 525nn5–6 middle-income countries. See low- and middle-income countries

militant anthropology  480 military assistance  197–211 civil-military cooperation  199–201, 205–8 disease prevention efforts  198 with Ebola virus  201, 204–6 foreign  201, 204–6 in humanitarianism  197, 199–201 long-term vs. short-term gains  207, 209, 211 in natural vs. complex emergencies  200–201, 210 opportunity costs of  200, 208 opposition to  199–200 overview 197–98 with poliovirus  206–8 in research and development  198–99 for tailgate medicine  208–10 with Zika virus  201–3 military capacity of states  149 Millennium Development Goals (MDGs) acceleration of progress on  326–27 access to medications and  607 agenda setting for  6, 329, 330, 333 funding for  106, 560 gender components of  248 on human right to health  494 omission of NTDs in  571 as planned development strategy  218 power in establishment and institutionalization of  74–75 targets of  226–27, 226t Mintrom, Michael  248 Money, John  237–38 Montgomery, Hugh  223 Moody, Michael P.  409 Moon, Suerie  605, 616 moral relativism  687 Morse, Stephen  127, 128 mortality rates. See also life expectancy alcohol use and  242 for children  59, 109, 152, 221, 227 of Ebola outbreak  204 for HIV/AIDS  114 for industrial proletariat  219 for NCDs  59, 627, 628t, 632 in refugee camps  151 from tobacco use  242, 661

720   index most-favoured nation principle  429 MPP (Medicines Patent Pool)  616 MSF. See Médecins sans Frontières Mukherjee, Suroopa  169 multiple-streams model  112, 335, 337–38 Murphy, Tim  124 Mykhalovskiy, Eric  166

N

NAFTA. See North American Free Trade Agreement Nakajima, Hiroshi  31, 32, 672 Narasimhan, Vasant  136 National Health Service (NHS)  447–48, 586 National Institutes of Health (NIH)  184, 594, 611 nationalism  10, 39, 369, 379, 441 National Philanthropic Trust  373–74 national treatment principle  429 Naylor, Thomas  471 NCD Alliance  376, 633, 646 NCDs. See non-communicable diseases neglected tropical diseases (NTDs)  569–80 ascendance on global health agenda  334 defined 569 Global Plan to Combat NTDs  571–72 global politics of  570, 579, 580 investments in  573, 578 omission in MDGs  571 poverty and  569, 571, 580 prevalence of  569, 579 public-private partnerships for  578, 580 summary of  573, 574–77t in Sustainable Development Goals  579 10/90 divide in health-related R&D and  569, 571 neo-liberal globalization backlash against  441 criticisms of  48–49, 52, 91–92 evolution of  53 global health politics and  369–70 health investments and  50–51 international development and  220–21 merger of global health regimes and  39–43 social determinants of health and  65

Washington Consensus and  38–39, 45–47, 220, 225 neo-liberalism. See also neo-liberal globalization civil society organizations in relation to  372, 377 critique of  92, 221–22 economic policies in  37, 41, 45, 220 erosion of professionalism in  457 framing of public health challenges in  632 healthcare reform and  450–55, 461 market policies in  37, 41, 427 policy convergence under  291 shock therapies in  221, 225, 472 socialism vs.  445, 448 structural adjustment programs and  38, 46–47, 371, 471–73 of Washington Consensus  38–39, 45–47, 220, 225 neo-Marxism 65–67 neorealist theory  330 Nestlé  392, 395 New Development Bank  304 new international economic order (NIEO)  44, 46, 456, 505–6, 591 New Washington Consensus  49–52 Ng, Nora Y.  301 NGOs. See non-governmental organizations NHS (National Health Service)  447–48, 586 nicotine. See tobacco use Nie Jing-Bao  696 Nietzsche, Friedrich  96 NIH (National Institutes of Health)  184, 594, 611 Nipah virus  518 Nishtar, Sania  643 non-aligned movement  87, 449, 456 non-communicable diseases (NCDs)  627–48 access to medications for  646 agenda setting for  328, 632 in BRICS countries  309 burden of  108, 629, 630, 648 development assistance for  287, 627 economic and material support for policy implementation 640–41

index   721 emergence as global health challenge 628–31 framework for analysis of global action on  635, 636t global movement for action on  631–34, 645–47 governance structures for  643–44 health inequality and  630–31 in human rights framework  636–37, 643 industry-led resistance to policies on 641–42 mortality rates for  59, 627, 628t, 632 normative instruments and policy guidance for  393, 635–37 political accountability mechanisms and  637–39, 638t public-private partnerships and  644–45 risk factors for  154, 628–31 societal changes resulting from  390 terminology issues  647 non-decision-making power  72 non-governmental organizations (NGOs) as actors in global health politics  33 in agenda setting  325, 332 business-interest  368, 377 civil-military cooperation by  199, 206 competition among  52 exercise of power by  63 on gender mainstreaming  248 government-organized 368 HIV/AIDS activism by  565 human rights as leverage for  501–2, 508 in human security  147 IGOs compared to  347 international development efforts of  217, 222 negotiation of health issues by  105 normative approach to human rights 494–502 North, Douglass C.  282, 284 North American Free Trade Agreement (NAFTA)  107, 440, 441, 474–75, 477 Novartis  573, 618, 670 Novotny, Thomas E.  306, 669 NTDs. See neglected tropical diseases Nunes, João  161

Nuremberg Code  688 Nye, Joseph S., Jr.  72, 110

O

Obama, Barack on antimicrobial resistance  131 on Ebola outbreak  123–24, 286 promotion of global health issues by  272 Obot, Isidore S.  242 OECD. See Organisation for Economic Co-operation and Development Office International d’Hygiène Publique (OIHP)  21, 22, 348 official development assistance (ODA)  92, 224, 288 Ogata, Sadako  149–50, 154, 155, 158n1 Ogden, Jessica  327 Oil for Doctors Program  108 older adults. See elderly populations O’Manique, Colleen  93, 187 O’Neill, Jim  131 “One World One Health” paradigm  10, 114 Ooms, Gorik  107, 493 opportunity costs debt crises and  288 of emergency measures in financial crisis 458 of health security  137–38 of military assistance  200, 208 of NCDs  631 of prioritizing partnerships over regulation 644 oral rehydration therapies (ORT)  30, 31, 49, 450 Orbinski, James  570–72 Organisation for Economic Co-operation and Development (OECD) competition from China  308 development assistance from  224, 226–27, 310, 312, 318 primary healthcare in  448 promotion of economic growth by  453 R&D investment by member countries  621 Organisation of African Unity  xiii orphan diseases. See neglected tropical diseases

722   index Oslo Declaration (2007)  109 Ostergard, Robert L., Jr.  143 Osterholm, Michael  185 Ostrander, Susan  418 Ottersen, Ole Petter  478 outbreak reporting  513–24 IHRs on  136, 513–16, 522–24 incentives for  136 ISRPs in  514–19, 521, 523 by nonstate actors  513–16, 519–24 timelines for  513 transparency in  516, 522

P

Pacific Island countries and territories (PICTs) 629–30 Packard, Randall  44–45, 49, 506 Pakistan, polio eradication efforts in  206–8 Pan American Health Organization (PAHO)  23, 24, 595 Pandemic Emergency Financing Facility  359, 542 pandemic fatigue  538 Pandemic Influenza Preparedness Framework (PIPF)  185, 188–89, 306, 536–37, 544 pandemics controlling 459 defined 20 preparedness planning for  132, 137 Parkhurst, Justin O.  329 participant observation  63, 71 partnerships. See also public-private partnerships defined 388b prioritizing over regulation  644 South-South  111, 313 Partzsch, Lena  411 Pasteur, Louis  583, 584 patent protections activism regarding  475 for antiretrovirals  613–15 as barriers to access  396 in Drugs for Neglected Diseases Initiative 572 economic globalization and  593 in free trade agreements  47, 271, 353 in global health agenda setting  333

Medicines Patent Pool  616 prioritization of commercial interests through 107 in research and development  4 path dependency  9, 252, 254, 355–57 PA (principal-agent) theory  349–52 patriarchy  90, 243, 246, 248, 251 PATRIOT Act of 2001  163 Payton, Robert L.  409 Peeters, Silvy  676 penicillin  198, 552 People’s Health Movement (PHM)  356, 372, 377, 505 PEPFAR. See US President’s Emergency Plan for AIDS Relief PepsiCo 395 Persad, Govind C.  562, 563 Peterson, Susan  351 Pfeiffer, James  63 pharmaceutical sector. See also medications advocacy groups in  356, 376 in BRICS countries  311–12, 318, 597 consolidation of  621 economic interests of  330–31 engagement with PPPs  396 on Essential Medicines List  609–10 globalization of  5, 622 ISDS provisions for  477 marketing code for  609 PIPF benefit sharing process for  536–37 profitability of  607 R&D activities in  415, 571, 621 tobacco control initiatives supported by 670 in TTIP negotiations  289 PHC. See primary healthcare PHEICs. See public health emergencies of international concern philanthrocapitalism  94, 377, 416 philanthropy 409–22 advantages in global health  414–17 components of  409–10 consumer-driven 413–14 corporate capture of  367 criticisms of  94, 417–21 defined 409 development assistance and  411–13

index   723 in global health governance  410, 416, 421–22 international relations and  410 lack of oversight and accountability  420–21 medical 34 performance-based models  374 power dimensions of  410–11, 418, 422 in public-private partnerships  39 Philip Morris International (PMI) Foundation for a Smoke-free World initiated by  642, 676 harm-reduction strategies  677 influence on tobacco laws  674 manifesto for smoke-free future  394 on market expansion  663 pack marker system  676 shares of menthol market  431 on WHO tobacco control efforts  664 WTO disputes and  434, 437 PHM (People’s Health Movement)  356, 372, 377, 505 PICTs (Pacific Island countries and territories) 629–30 Piketty, Thomas  458 Pillay, Yogan  507 Pillinger, Mara  356 Piot, Peter  xiii, 6, 32, 129, 133–34, 155, 503, 558 PIPF. See Pandemic Influenza Preparedness Framework Pisani, Elizabeth  283 place-based stigma  66 plague. See bubonic plague planetary boundaries  223 planetary politics  10 planned (intentional) development  217–18, 224–29 pluralism, in bioethical frameworks  687–93, 696 plurilateral summit institutions (PSIs)  303, 305, 306 PMI. See Philip Morris International Pneumocystis carinii  32, 553 Pogge, Thomas  480 Polanyi, Karl  219, 220, 229 poliovirus agenda setting for  328, 594 eradication campaigns  206–8, 415, 595–96

global surveillance systems  518–19 outbreak reporting  517 PHEIC declaration for  166 vaccination for  206–8, 583, 588 political capacity of states  147 political determinants of health  62 political economy critique of  91–93 future research directions  478 good governance lexicon in  455 of health  64–65, 372, 469–77, 479–80 Keynesian 448 market mechanisms in governance of  447 political-cultural analysis vs.  38 of redistribution  285 structural adjustment programs and 471–74 of trade  474–77 political rights  494–95, 497–501 political science conceptualizations of power in  64–65 in global health politics  7, 8 of health inequality  285 of social determinants of health  285 political settlements  284, 479 politics. See also global health politics of global health governance  172, 272–76 high/low distinction in  5, 41, 106 of neo-liberalization  38 planetary 10 of representation  94–95, 165 of security  162–64 population control  27–29, 356 populist movements  10 post-positivism 162 Poteat, Tonia  66 poverty access to healthcare and  461 capabilities approach to  154 children in  153 cycle of  154, 156, 631 economic growth and  228–29 global health and  51, 154–55 HIV/AIDS and  155, 552, 559 human security and  152, 154–55 moral responsibility for  480 NCDs and  154, 631

724   index poverty (Continued) neglected tropical diseases and  569, 571, 580 prevalence of  370 reframing as domestic issue  479 as social determinant of health  285 strategies for reduction of  5, 6, 48, 285 women in  153–54 Poverty Reduction Strategy Programs (PRSPs) 471 power agency forms of  61, 65, 71–73 analytical frameworks for  74–75 anthropological perspective on  62–64, 73 asymmetries related to  291, 470, 478 biopower 95–96 compulsory 74 conceptualizations of  61–62, 71–72, 110 conflictual 72 critical race theory on  67–68 dispositional 72 epistemic 72 in global health governance  10, 273–74 hard  72, 104, 110 health inequality in relation to  62–67, 70–73, 469 hegemonic 72 ideational 4 institutional  72, 74, 355 of intergovernmental organizations 348–54 intersectionality and  68–70, 241 literature review  70–73 material  4, 62, 73, 355, 402 non-decision-making 72 philanthropy and  410–11, 418, 422 in political science  64–65 productive  72, 74 in securitization theory  94–95 smart  104, 115 sociological perspective on  65–67, 73 soft  72, 104, 110–11, 114, 306, 635 sources of  73 structural  61, 65, 71–74 symbolic 72 transitive 72 of transnational corporations  369, 388

power cube framework  74 PPPs. See public-private partnerships praziquantel 330 pre-exposure prophylaxis (PrEP)  562 prejudice. See discrimination; stigma prescription drugs. See medications Price-Smith, Andrew  125, 132 primary healthcare (PHC) Alma-Ata Declaration on  30, 44–47, 51, 224–25, 315, 329, 371 in BRICS countries  315 centrality to social determinants of health 456 civil society organizations in promotion of 371–72 defined 462n2 globalization and  41 GOBI interventions for  30–31, 49, 450 in healthcare reform  449–53 for human security  145 in new international economic order  505–6, 591 in postcolonial society  43, 44 principles of  449 selective. See selective primary healthcare vaccination programs integrated into 591–92 vicissitudes of  29–31 principal-agent (PA) theory  349–52 principled authority  275 privacy issues. See confidentiality productive power  72, 74 professionalism, erosion of  457 Project Cerberus  672 Project Last Mile  397 ProMED  517–19, 521–23 protectionism  441, 453, 593 PRSPs (Poverty Reduction Strategy Programs) 471 PSIs (plurilateral summit institutions)  303, 305, 306 public goods  271, 445, 452–53, 572–73, 612 public health emergencies of international concern (PHEICs)  165–66, 187, 190, 357, 513 public-private partnerships (PPPs) as actors in global health politics  4, 249, 271

index   725 in agenda setting  331 as coordinating mechanisms  51 corporate social responsibility and  396, 397 defined  396, 578 emergence of  370, 373, 401 GISN transformation to  536 global health investment by  39, 50, 225 for health financing  452 NCDs and  644–45 for neglected tropical diseases  578, 580 for product development  607–8, 612, 619 for vaccinations  593–94, 596 punctuated equilibrium theory  335, 338

Q

quantitative easing  457

R

racism  63, 67 Rajchman, Ludwik J.  22 Rancière, Jacques  97–98 R&D. See research and development Rao-Gupta, Geeta  254 rape 153 Raphael, Dennis  65 rational actor model  65 rational institutionalist approach  350, 353 Rawls, John  247 Raworth, Kate  223, 230 RDS (Revised Drug Strategy)  609, 610 Reagan, Ronald  28, 47, 220, 556 realist theory of international relations  91, 112–13, 493 Reddy, K. S.  269, 271 (RED) project  93–94, 413–17 Reed, Walter  21 re-emerging infectious diseases  32–33, 88, 535, 543 reflexive analysis  68, 75 refugee camps  151 regulatory capitalism  642 regulatory cooperation mechanisms  438–40 Reich, Michael R.  329, 330 Reid-Henry, Simon  42, 52 Reis, Andreas  460

relativism, in bioethical frameworks  687–89, 692, 696 reporting outbreaks. See outbreak reporting representation politics  94–95, 165 research and development (R&D) investment in  415, 573, 578, 607–8, 621 military assistance with  198–99 non-profit models for  619 patent protections and  4 in pharmaceutical sector  415, 571, 621 private sector support for  401, 412, 611 reform of global system for  620 10/90 divide in  569, 571, 612 for vaccines  532, 539, 593, 597 resistance to medications. See antimicrobial resistance Resolution 1308 (UNSC)  xiii, 110, 271, 557–58 Responsibility to Protect agenda  5, 272, 499 Revised Drug Strategy (RDS)  609, 610 Ricardo, David  219, 230 Ricoeur, Paul  96 risk-based mentality  165–66 R.J. Reynolds (RJR)  431 Robinson, William I.  290, 479 Rockefeller, John D.  23, 390, 420 Rockefeller, John D., Jr.  410 Rockefeller, Nelson  410 Rockefeller Foundation as actor in global health politics  4 establishment of  22, 390 International Health Division  410, 415–20 medical objectives of  23, 30 neglected diseases initiative  611 on planetary health  10 population control policies  356 on primary healthcare  49, 372 Trading Tobacco for Health Initiative  674 Rodan, Gary  379 Rodriguez, Mariela A.  330 Roemer, Ruth  666, 670 Rogers, Wendy  169, 170 Roll Back Malaria  51 Rotary International  4, 373, 596 rotavirus 599 Rothschild, Emma  144 Rowden, Rick  221, 222 Rowell, Andy  676

726   index Rubin, Robert  414 Ruckert, Arne  103, 397 Ruger, Jennifer Prah  59, 301 rule-based authority  349 Rushton, Simon  113, 123, 187, 271, 329–31 Russell, Sarah  155 Russia. See also BRICS countries; Soviet Union cholera outbreak in  32, 151–52 development assistance from  303, 308, 310, 311 in Group of Eight  116n1, 303–4 military assistance from  200 post-Soviet mortality crisis in  221 privatization in  230n1 state-centric approach in  314 Rutzen, Douglas  379

S

Sabatier, Paula A.  338 Sabin, Albert  583, 588 Sainsbury, Diane  66 Salk, Jonas  583, 588 Sanders, David  445 SAPs. See structural adjustment programs SARS. See severe acute respiratory syndrome Saudi Arabia, handling of MERS outbreak in  518, 520–24 Schaaf, M.  75 Scheper-Hughes, Nancy  480 Schervish, Paul G.  418 Scholte, Jan A.  368, 372–73, 377 Schrecker, Ted  40, 281, 469 Schuyt, Theo N. M.  410 Scott, Kerry  66 SDGs. See Sustainable Development Goals SEATCA (Southeast Asia Tobacco Control Alliance)  669, 674 The Second Sex (de Beauvoir)  237 securitization theory  94–95, 134, 163–65 security. See biosecurity; critical security studies; health security; human security “security as emancipation” approach  164, 168, 173 Security Council. See United Nations Security Council security dilemmas  181, 183

Seeley, Elizabeth  402 selective primary healthcare (SPHC) advocacy for  506, 507 dominance in global health policy  371 GOBI interventions for  30–31, 49, 450 principal recipients of  249 targeted interventions in  50 self-inflicted violence  151 Sell, Susan K.  275, 475 Sen, Amartya  145, 149–50, 154, 155, 158n1, 282 Sen, Gita  69, 70 seniors. See elderly populations September 11 attacks (2001)  6, 129, 130, 162–63, 379 severe acute respiratory syndrome (SARS) accidental infections involving  185 agenda setting for  334 as focusing event  113 as impetus for addressing global health issues  6, 103, 307 outbreak reporting  136, 516, 518 response to  5, 268, 269, 351, 535 as security threat  128 travel restrictions for  269, 331, 351 sex (biological)  238–40 sexually transmitted diseases (STDs). See also HIV/AIDS agenda setting for  327, 328, 331–32 children and  153 prevention strategies  555 women’s risk for  152 sexual orientation. See homosexuality sexual violence  151, 153 Shaw, Leslee J.  245 Shawar, Yusra Ribhi  59 Shepherd, Philip  663 Shetty, Devi  316 Shiffman, Jeremy  72, 272, 325, 330, 633 Shue, Henry  500, 501 Siddiqi, Jared  350 Silva, Diego S.  685 Siracusa Principles (UN Commission on Human Rights)  135 smallpox eradication campaigns  29, 44, 224, 553, 589–90, 594 International Health Regulations on  25

index   727 population decline due to  125, 198 vaccination for  198, 552, 583, 584, 589–90, 599 smart power  104, 115 Smith, Frank  197, 269 Smith, James A.  250 Smith, Julia  387 Smith, Richard  106, 114, 115 Smith, Stephanie L.  325, 330 smoking. See tobacco use Snow, John  20 Snyder, Jeremy  685 social constructionism  252, 633 social determinants of health globalization effects on  40, 47, 65 horizontal approaches to  49 intersectionality and  240–41 neglect of  459 political science of  285 poverty and  285 primary healthcare and  456 WHO Commission on  48, 59, 238, 470, 552 working conditions and  473 social distancing  132, 135, 190, 542 socialism  33, 239, 445, 448–49 social media disadvantages of  379 governmental control of  523 outbreak reporting through  514, 517, 519, 521 social medicine  22, 23, 43, 44 social rights. See International Covenant on Economic, Social, and Cultural Rights social spaces  66 social violence  379, 459 socio-economic status  59, 65, 152. See also poverty sociology, conceptualizations of power in  65–67, 73 socio-medical perspectives  26, 29, 32, 34 soft power  72, 104, 110–11, 114, 306, 635 sole proprietorships, defined  388b Sommer, Marnie  332 Soper, Fred L.  23 Sotomayer, Arturo  202 South Africa. See also BRICS countries access to medications in  613 apartheid regime in  553

bubonic plague in  21 development assistance from  303, 311, 313 Ebola outbreak response by  191 life expectancy in  221 pharmaceutical sector in  311 Southeast Asia Tobacco Control Alliance (SEATCA)  669, 674 Soviet Union. See also Russia as alternative to capitalism  447 in Cold War  24–25, 87 health services in  24 HIV/AIDS disinformation campaign by 554 on population control  28 smallpox eradication efforts  29, 589–90 Spanish influenza pandemic (1918)  532, 534, 539–40, 543 Sparke, Matthew  37, 372, 377 SPHC. See selective primary healthcare SPS Agreement  428, 434 Sridhar, Devi  353–54, 633, 634 Stahn, Carsten  499 Stalin, Joseph  24 Stamps, Timothy  666 Stanton-Jean, Michele  693 states 281–92. See also foreign policy as actors in global health politics  4 capacity to govern  147–49, 148f, 155–57 declining relevance of  281, 289–91 future research needs  292 global health concerns of  286–89 healthcare provisions from  23, 24, 282–85 internal complexity of  281–82 as political units of international relations 40 role in BRICS countries  313–15 transnational 290–91 STDs. See sexually transmitted diseases Stiglitz, Joseph  473, 504 stigma. See also discrimination definitions of  66 epidemics and  20, 21, 32 of HIV/AIDS  32, 66, 94, 167, 556 place-based 66 Storeng, Katerini T.  329, 374 Strange, Susan  289, 291 Streeck, Wolfgang  229

728   index structural adjustment programs (SAPs) conditionalities of  46, 353, 448, 472–73 criticisms of  221 negative impact of  454–55, 472–74 neo-liberalism and  38, 46–47, 371, 471–73 structural power  61, 65, 71–74 structural violence  47, 52, 62–64, 72, 377, 480 structural vulnerability  62–64, 72 Stuckler, David  186 sub-Saharan Africa antiretroviral access in  413, 416 child mortality rates in  59 economic decline in  221 HIV/AIDS in  128, 129, 286 life expectancy in  221, 454, 458 neo-liberal shock therapies in  472 pharmaceutical sector in  311 public health services in  88 structural adjustment programs in  472, 473 tobacco use in  399 subsistence rights  499 substance use. See alcohol use; tobacco use Sumner, Andy  285 Supari, Siti Fadilah  188, 536 Sustainable Development Goals (SDGs) access to medications and  607 agenda setting for  6, 329, 333 costs associated with  288 foundational concepts of  578–79 gender components of  248 on human right to health  494 for NCDs  639 neglected tropical diseases in  579 as planned development strategy  218 targets of  227–29, 228t, 285, 288 swine flu. See H1N1 symbolic power  72 Szreter, Simon  126, 283

T

tailgate medicine  208–10 Tarrow, Sidney G.  368 Task Force for Child Survival  592, 595 Taylor, Allyn  666, 670 Taylor, Carl  25 TB. See tuberculosis

Technical Barriers to Trade (TBT) Agreement  428, 430 technical capacity of states  147 ten Have, Henk  693, 694 terrorism  6, 129, 130, 162–63, 379. See also bioterrorism Thatcher, Margaret  47, 220, 230n1, 448, 555 Therborn, Göran  220 ‘t Hoen, Ellen F. M.  572, 605 Thomas, Stephen B.  68 Thompson, Donald  208 Thompson, Tommy  614 TNCs. See transnational corporations Tobacco Free Initiative (TFI)  394, 631, 666–71 tobacco use  661–77. See also Framework Convention on Tobacco Control; transnational tobacco companies collective action for regulation of  390–91 as commercially driven pandemic  663–64 cost of interventions for reduction of  632 domestic control of  307 electronic nicotine delivery systems  394–95, 642 evidence base against  667–68 gender differences in  241–42 in global health policy agenda  328 governance on  276 health effects of  661–62 mortality rates from  242, 661 as NCD risk factor  629–31 reframing as public health issue  89, 665–72 trade policies impacting  429–33, 439 underestimation of health risks  399 Tobin, John  498–99, 502 Toebes, Brigit  644 TPP. See Trans-Pacific-Partnership trade liberalization economic growth through  446 food industry and  476, 629–30 globalization effects on  6, 470 health effects of  470, 629–30 non-tariff trade barriers and  436 power exerted through  64 transnational corporations and  427 Washington Consensus on  46

index   729 Trans-Atlantic Trade and Investment Partnership (TTIP)  107, 289, 435–41 transgender populations  66, 240, 252 transitive power  72 transmissible chronic diseases  647 transnational corporations (TNCs) cash reserves held by  292n3 consolidation of ownership  388, 393 food and beverage  477 good governance lexicon in  455 intellectual property protections for  107 investor-state dispute settlement for  436–37, 477 power of  369, 388 public policy influence of  64 regulatory cooperation mechanisms and 438–39 reputation management by  395 role in global economy  291 standard setting influenced by  398–99 tax avoidance by  288, 370 trade liberalization and  427 value chains controlled by  476 vulnerability of workers in  169 transnational tobacco companies (TTCs) consolidation of  391 expansion into emerging markets  663 harm-reduction initiatives  676–77 on illicit tobacco trade  675–76 marketing tactics used by  391 political repositioning of  394 profitability of  662 Project Cerberus developed by  672 standard setting influenced by  398–99 venue shopping by  439 Trans-Pacific-Partnership (TPP)  107, 116n3, 289, 399, 435–41 travel restrictions for Ebola virus  136–37, 190–91, 331 health security and  136–37, 165, 189–91, 207 HIV/AIDS and  331, 556 H1N1 and  136, 331 SARS and  269, 331, 351 TRIPS. See Agreement on Trade-Related Aspects of Intellectual Property Rights tropical medicine. See also neglected tropical diseases

as academic discipline  22 colonialism and  20, 44, 125–26, 171, 199 exclusionary nature of  189 gender in  248 Rockefeller Foundation division of  23 True, Jacqui  248 Trump, Donald America First policies of  287 antiglobalism of  39, 53 election of  10 ideological undermining of truth by  115 on US withdrawal from TPP  440, 441 TTCs. See transnational tobacco companies TTIP (Trans-Atlantic Trade and Investment Partnership)  107, 289, 435–41 tuberculosis (TB). See also Global Fund to Fight AIDS, Tuberculosis and Malaria agenda setting on  327, 328, 331 in BRICS countries  309 global surveillance systems  518–19 outbreak reporting  517 as re-emerging disease  88 vaccination for  585–88, 599 Turner, Ted  410, 670 typhus 585–86

U

UDBHR. See Universal Declaration on Bioethics and Human Rights UDHR. See Universal Declaration of Human Rights UHC. See universal health coverage UN. See United Nations UNAIDS. See Joint United Nations Programme on HIV/AIDS UNDP (United Nations Development Programme)  144–46, 454, 591 UNESCO (United Nations Educational, Scientific, and Cultural Organization)  685, 688–90, 693–95 UNFPA (United Nations Population Fund)  28, 356, 397 UNGA. See United Nations General Assembly UNIATF (United Nations Interagency Task Force on NCDs)  639, 640, 642 UNICEF. See United Nations Children’s Fund

730   index Unilever 395 unintentional (immanent) development  217, 218–23, 229 UNITAID  397, 607, 615, 616 United Kingdom alcohol use patterns in  242–43 Brexit vote in  10, 441, 563 Department for International Development  205, 303, 325, 674 development assistance from  287 global health diplomacy by  109, 112–13 HIV/AIDS public information campaigns in 555 influenza vaccination campaigns in  533–34 life expectancy in  219 medication stockpiles held by  137 military assistance from  204–6 National Health Service  447–48, 586 privatization in  47, 230n1 Social Issues Research Centre  376 tobacco use patterns in  242 tropical medicine schools in  22 utilization of health services in  245 vaccination adoption in  584–86, 598 United Nations (UN) on antimicrobial resistance  131 Commission on HIV/AIDS and Governance in Africa  560 Commission on Human Security  147, 149–56, 158n1 Convention on the Rights of the Child  494, 644 establishment of  23 Global Compact  370 on HIV/AIDS as security issue  94 on influenza pandemic preparedness  535 International Covenant on Civil and Political Rights  494–95, 497–501 International Covenant on Economic, Social, and Cultural Rights  106, 144, 494, 497–502, 637 MDGs. See Millennium Development Goals negotiation of health issues by  105 Responsibility to Protect agenda  5, 272, 499 SDGs. See Sustainable Development Goals Universal Declaration of Human Rights  144, 496, 497, 499

United Nations Children’s Fund (UNICEF) Child Survival Revolution  49, 326, 450 establishment of  23, 586–87 on influenza pandemic preparedness 538–39 on primary healthcare  30, 31, 49, 449, 506 on structural adjustment programs  454–55 vaccination support from  586–87, 591, 596, 597 United Nations Development Programme (UNDP)  144–46, 454, 591 United Nations Economic and Social Council (ECOSOC)  238, 247, 639 United Nations Educational, Scientific, and Cultural Organization (UNESCO)  685, 688–90, 693–95 United Nations General Assembly (UNGA)  xiii, 325, 634, 637–39, 642–43 United Nations Interagency Task Force on NCDs (UNIATF)  639, 640, 642 United Nations Population Fund (UNFPA)  28, 356, 397 United Nations Security Council (UNSC) on Ebola outbreak  191, 271, 331 functions of  325 HIV/AIDS on agenda of  128–29, 133–34, 331 Resolution 1308 adopted by  xiii, 110, 271, 557–58 Resolution 2177 adopted by  191 United States biodefense activities conducted by  181–83 bubonic plague in  21 cigarette flavouring dispute with Indonesia 429–33 in Cold War  24–25, 87 Declaration of Independence  495–96 development assistance from  109, 286–87, 310 disease eradication efforts in  596 Ebola outbreak response by  123–24 global health funding from  25–26, 31, 53 health inequality in  59 health security threats to  94, 123–24 influenza vaccination campaigns in  533–34 isolationist policies of  22 Marshall Plan implemented by  224 MEDCAP use by  208–10 medication expenditures in  619

index   731 medication stockpiles held by  137 military assistance from  200, 204–6 neo-liberal economic policy in  45 privatization of healthcare in  47 September 11 attacks (2001)  6, 129, 130, 162–63, 379 Universal Declaration of Human Rights (UDHR)  144, 496, 497, 499, 691 Universal Declaration on Bioethics and Human Rights (UDBHR)  685–97 criticisms of  685–86, 693 on cultural diversity  690–94 legitimacy of  686, 689, 690, 694 objectives of  689 on pluralism  691–93 as political document  692–93 preamble to  690–91 refinement of  696–97 terminology considerations  686–88, 695 universality of application  686, 689–90, 696 universal health coverage (UHC) advocacy for  473 in BRICS countries  309, 315–16 erosion of support for  454 funding for  285, 288, 291 on global health agenda  283, 286, 329 mechanisms for achievement of  460–61 monitoring framework for tracking progress toward  304 NCDs and  645 opposition to  507 political nature of  283–84 WHO support for  506 universalism, in bioethical frameworks  686–90, 692, 694–96 UNSC. See United Nations Security Council US Agency for International Development (USAID)  26–28, 30, 49, 205, 397 US Declaration of Independence (1776) 495–96 US President’s Emergency Plan for AIDS Relief (PEPFAR) funding for  225, 274, 287, 333 generic medication purchases by  616 as global health diplomacy  108, 110, 114 motivations for formation of  270, 272, 560, 615

scope of program  134 “utopia as method” approach  75

V

vaccinations 583–600. See also Global Alliance for Vaccines and Immunizations access to  42, 188, 397, 536, 544–45, 607 BCG 585–88 Children’s Vaccine Initiative  593–94 Cold War rivalries and  588 compulsory  165, 584, 598 diphtheria 584–85 economic globalization and  592–96 global politics of  597–600 GOBI interventions and  30, 31, 49, 450 hepatitis B  206, 598, 599 influenza  186, 188–89, 531–41, 544–45 mass vaccination campaigns  586–88 measles 598 opposition to  585, 587 overview 583 poliovirus  206–8, 583, 588 production centers for  311–12, 597 profitability of  600 as public health tool  584–86 R&D investment in  532, 539, 593, 597 rotavirus 599 smallpox  198, 552, 583, 584, 589–90, 599 standardization of  598 tuberculosis  585–88, 599 typhus 585–86 WHO programs for  206, 590–92 yellow fever  415, 416 vaping 394–95 Vaughan, Patrick  664 violence in civil-military relations  202 collective 151 genocide  153, 499 global health and  150–54 human security and  150–54 interpersonal  151, 152, 157 self-inflicted 151 sexual  151, 153 social  379, 459 structural  47, 52, 62–64, 72, 377, 480 women and  152–53, 248, 335

732   index von Hayek, Friedrich  220, 230 von Unger, Hella  70 vulnerability actual vs. potential  169 in conflict areas  152, 153, 157 in critical security studies  168–70, 173 defined 168 to disease  33, 39, 126, 128, 173 income inequality and  47 intersectionality and  241 relational view of  169–70 stigma as reinforcement of  66 structural  62–64, 72

W

Wallgren, Arvid  585 Walsh, Julia A.  249, 506 Walt, Gill  90, 112, 327 Waltz, Kenneth  8 Wang, Yingying  245 Warren, Kenneth S.  249, 506 Washington, George  198 Washington Consensus healthcare reform influenced by  454, 456 inadequacies of  48, 456 on market-based efficiency  446 neo-liberalism of  38–39, 45–47, 220, 225 New Washington Consensus  49–52 origins of term  45–46, 288 Wasunna, Angela A.  571 Watson, James L.  128 Watson, Scott  189 Weir, Lorna  166 Weisbrod, Burton  414 welfare state  64–66, 447, 448 Wellcome Trust  4, 411 Wendt, Alexander  493 West Africa Ebola outbreak. See Ebola virus disease What Is Enlightenment (Kant)  86 Whiteside, Alan  551 WHO. See World Health Organization Wilkinson, Richard  552, 565n2 Williams, Michael C.  162 Williams, Owain David  271, 329 Williamson, John  45–46, 50

Wilsnack, Richard W.  242 Wilsnack, Sharon C.  242 WIPO (World Intellectual Property Organization) 360 WMA (World Medical Association)  688 Wolff, Jonathan  169 women. See also gender in conflict areas  153, 157 discrimination against  70 family-planning programs targeting  28 menstrual hygiene management for  331, 332 in poverty  153–54 reproductive health of  53, 153, 243–44, 248, 333 violence against  152–53, 248, 335 Woodling, Marie  329 Woods, Ngaire  474 World Bank as actor in global health politics  4, 218, 271, 349 agenda setting by  225, 326 conditions for loans from  593 Curbing the Epidemic report  631, 668 epistemology of hunger  353–54 good governance lexicon in  455 on influenza pandemic preparedness  535, 538–39, 542 Investing in Health report  33, 50–51, 450, 473, 551, 612 Pandemic Emergency Financing Facility  359, 542 policymaking influences  50, 51, 92 poverty as defined by  285 on primary healthcare  49 response to debt crises  38, 45–46, 88, 471 structural adjustment programs  38, 46, 221, 353, 371, 448, 471–73 in transnational state  290 on universal health coverage  473 World Economic Forum  6, 53, 229, 594, 597, 670 World Health Organization (WHO) as actor in global health politics  4, 349 agenda setting by  326, 330 on antimicrobial resistance  131

index   733 BRICS countries’ involvement with  304, 307, 314 bureaucratization and  350 CIOMS established by  688 Commission on Macroeconomics and Health  51, 472, 573 Commission on the Social Determinants of Health  48, 59, 238, 470, 552 criticisms of  9, 33, 265 on diet and physical activity  115, 636, 641 diplomatic instruments of  112b, 353 Ebola outbreak response  9, 265, 275, 359 Essential Medicines List  608–10, 615 establishment of  19, 24, 218, 247, 266 FCTC. See Framework Convention on Tobacco Control fragmentation within  352, 355 Framework for Engagement with Non-State Actors  375 functions of  325, 348–49 funding for  25–26, 274, 373, 409 Global Code of Practice on the International Recruitment of Health Personnel 112b Global Health Workforce Network  246 Global Influenza Surveillance Network  188, 533, 534, 536 Global Programme on AIDS  352, 358–59, 556 Global Strategy to Reduce the Harmful use of Alcohol  112b, 391 Health for All by the Year 2000 strategy  30, 371, 495, 505, 608 on health security  128, 186 HIV/AIDS epidemiological scenarios developed by  556–57 IHRs. See International Health Regulations international development efforts of 224–25 legitimacy challenges for  111–12, 671–72 on NCDs  393, 633, 635–43 on neglected tropical diseases  569, 571–72 negotiation of health issues by  105 normative power for health promotion  111–12, 273

outbreak reporting to  513–19, 522–24 Pandemic Influenza Preparedness Framework  185, 188–89, 306, 536–37, 544 policymaking shifts at  50, 51, 93 on population control  28 preamble to constitution of  24, 27, 44 on primary healthcare  31, 49, 449 Revised Drug Strategy  609, 610 SARS outbreak response  269, 351 Set of Recommendations on the Marketing of Food and Non-alcoholic Beverages to Children  115, 633 Tropical Diseases Research program  248 on universal health coverage  506 vaccination programs  206, 590–92, 595–97 vertical campaigns of  26–27 violence as categorized by  151 weakening of  373–74 World Intellectual Property Organization (WIPO) 360 World Medical Association (WMA)  688 World Trade Organization (WTO). See also Agreement on Trade-Related Aspects of Intellectual Property Rights on compulsory licensing for generics  613, 614, 617 dispute settlement mechanisms  429–35, 455 establishment of  428, 441, 474 General Agreement on Trade in Services  428, 434, 452 negotiation of health issues by  105 policymaking influences  92 SPS Agreement  428, 434 Technical Barriers to Trade Agreement  428, 430 in transnational state  290 US-Indonesia dispute on cigarette flavouring 429–33 Worsnop, Catherine  353 WTO. See World Trade Organization

X

Xi Jinping  305

734   index

Y

Yach, Derek  394, 666–67, 670, 673 yellow fever International Health Regulations on 25 quarantine regulations for  126 as re-emerging disease  32 transmission of  20–21 vaccination for  415, 416

Youde, Jeremy  1, 52, 93, 271, 409 youth. See children and adolescents

Z

Zaki, Ali Mohamed  520–22, 525n5 Zhadnov, Victor  589 Zika virus  103, 166, 201–3 Zimmer, Zachary  153 zoonotic diseases  127, 532, 551, 554, 572 Zuckerberg, Mark  4, 413