Global Health Governance in International Society 0198813058, 9780198813057

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Global Health Governance in International Society

Global Health Governance in International Society Jeremy Youde

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Great Clarendon Street, Oxford, OX2 6DP, United Kingdom 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 in certain other countries © Jeremy Youde 2018 The moral rights of the author have been asserted First Edition published in 2018 Impression: 1 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 reprographics rights organization. Enquiries 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 Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America British Library Cataloguing in Publication Data Data available Library of Congress Control Number: 2017948009 ISBN 978–0–19–881305–7 Printed and bound by CPI Group (UK) Ltd, Croydon, CR0 4YY Links to third party websites are provided by Oxford in good faith and for information only. Oxford disclaims any responsibility for the materials contained in any third party website referenced in this work.

For Ben

Acknowledgements

Writing a book is a journey—quite literally in this case. I started writing this book while I was a member of the Department of Political Science at the University of Minnesota Duluth. My colleagues there—Mary Caprioli, Runa Das, Cynthia Rugeley, Geoff Sheagley, Joseph Staats, and Shannon Walsh— made for an engaging and vibrant atmosphere. I especially want to thank Paul Sharp, who was kind enough to hire me at UMD in the first place, and Geraldine Hughes, who served as my sounding board more times than I can remember. In 2016, I joined the Department of International Relations at the Australian National University and found a vibrant intellectual and research environment (in addition to really good coffee and the chance to see kangaroos in the wild when I walked home from campus). My colleagues at ANU—Bina D’Costa, Mathew Davies, Lorraine Elliott, David Envall, Luke Glanville, Mary Lou Hickey, Haroro Ingram, Cecilia Jacob, Vanessa Newby, Susan Sell, William Tow, Ben Zala, and Feng Zhang—have consistently challenged me and helped me to avoid unnecessary errors. It can be a bit intimidating to write a book from an English School perspective in a building named for Hedley Bull, but my colleagues made the process far more enjoyable. I presented the ideas in this book at numerous conferences, and I am so thankful for all the smart scholars who have reviewed, commented on, and helped me to improve my work. Alex Bellamy, Jon D. Carlson, Sara Davies, Stefan Elbe, Christian Enemark, Harry Gould, Sophie Harman, Steven Hoffman, Yanzhong Huang, Adam Kamradt-Scott, Robert Ostergard, Amy Patterson, Nathan Paxton, Mara Pillinger, Anne Roemer-Mahler, Simon Rushton, Matthew Weinert, and Owain Williams have all provided valuable insights throughout the years. I can’t say enough good things about Jack Amoureux and Brent Steele—friends and inspirations since our youthful days in seminars together in Iowa City. I am also forever indebted to my friends in my running groups—Canberra Frontrunners and ECNf—for helping to remind me to get out of the office so I could have those ‘a-ha’ moments that have made this a better book.

Acknowledgements

The amazing staff at Oxford University Press—Dominic Byatt, Sarah Parker, and Olivia Wells—have gone above and beyond to make the publication process a breeze. Parts of some chapters have appeared previously under the title ‘Global Health Governance in International Society’ from Global Governance: A Review of Multilateralism and International Organizations, Volume 23, Number 4, copyright © 2017 by Lynne Rienner Publishers, Inc. They are used here with permission of the Publisher. Finally, this book is for Ben. I can’t even begin to repay him for all that he’s done for me in so many different ways.

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Contents

List of Abbreviations

Introduction

xi 1

1. The English School and the Emergence of International Society

11

2. Primary Institutions, Secondary Institutions, and Moral Obligation

32

3. The Evolution of Global Health Governance

50

4. Contemporary Global Health Governance Actors

75

5. Development Assistance for Health

95

6. International Society Confronts Ebola

115

7. China, International Society, and Global Health Governance

133

Conclusion Works Cited Index

153 161 185

List of Abbreviations

AFRO

World Health Organization Regional Office for Africa

ART

antiretroviral therapy

BMGF

Bill and Melinda Gates Foundation

BRICS

Brazil/Russia/India/China/South Africa

CCMs

Country Coordinating Mechanisms

CDC

United States Centers for Disease Control and Prevention

CIA

United States Central Intelligence Agency

CZI

Chan Zuckerberg Initiative

DAC

Development Assistance Committee

DAH

development assistance for health

ECOSOC

Economic and Social Council of the United Nations

FOCAC

Forum on China–Africa Cooperation

G8

Group of Eight

GAVI Alliance

Global Alliance for Vaccines and Immunization

Global Fund

Global Fund to Fight AIDS, Tuberculosis, and Malaria

GPA

Global Programme on AIDS

GPEI

Global Polio Eradication Initiative

HIV/AIDS

human immunodeficiency virus/acquired immune deficiency syndrome

HSS

health systems strengthening

ICJ

International Court of Justice

IHD

International Health Division of the Rockefeller Foundation

IHME

Institute for Health Metrics and Evaluation

IHR

International Health Regulations

IHR (2005)

International Health Regulations (2005)

ISC

International Sanitary Conferences

ISR

International Sanitary Regulations

LNHO

League of Nations Health Office

LSHTM

London School of Hygiene and Tropical Medicine

List of Abbreviations MDGs

Millennium Development Goals

MDR-TB

multidrug-resistant tuberculosis

MSF

Médecins Sans Frontières/Doctors Without Borders

NATO

North Atlantic Treaty Organization

NCDs

non-communicable diseases

NGOs

non-governmental organizations

OAU

Organization of African Unity

OECD

Organisation for Economic Cooperation and Development

OIHP

Office International d’Hygiène Publique/International Office of Public Hygiene

PEPFAR

President’s Emergency Plan for AIDS Relief

PHC

primary health care

PHEIC

Public Health Emergency of International Concern

PMI

President’s Malaria Initiative

PPPs

public–private partnerships

PRC

People’s Republic of China

R2P

Responsibility to Protect

RF

Rockefeller Foundation

SARS

severe acute respiratory syndrome

SDGs

Sustainable Development Goals

SIM

Serving in Mission

SPHC

selective primary health care

TB

tuberculosis

UN

United Nations

UNAIDS

Joint United Nations Program on HIV/AIDS

UNICEF

United Nations Children’s Fund

UNMEER

United Nations Mission for Emergency Ebola Response

UNSC

United Nations Security Council

USAID

United States Agency for International Development

WHA

World Health Assembly

WHO

World Health Organization

WTO

World Trade Organization

XDR-TB

extensively drug-resistant tuberculosis

xii

Introduction

On 23 March 2014, the World Health Organization’s Global Alert and Response division released a four-line news item. It announced that the Ministry of Health of Guinea had confirmed the presence of human cases of Ebola in the southeastern part of the country. By the time the announcement came, the Ministry had identified forty-nine cases of the disease, causing twenty-nine deaths (World Health Organization 2014a). This simple announcement triggered one of the largest responses to a global health event in history. Though the World Health Organization (WHO) has received widespread criticism for its slow response to the outbreak, the international community mobilized rapidly and in an unprecedented manner after WHO declared the Ebola outbreak in West Africa to be a Public Health Emergency of International Concern (PHEIC) on 8 August 2014. By the end of 2014, donors had pledged $2.89 billion in support of the international response to Ebola—an amount that outstrips the amount requested by international leaders (Grépin 2015). The United Nations Security Council (UNSC) passed Resolution 2177 on 18 September 2014, which, for the first time in the organization’s history, explicitly declared an infectious disease outbreak to be ‘a threat to international peace and security’ (United Nations Security Council 2014). The next day, the United Nations General Assembly authorized the creation of the United Nations Mission for Ebola Emergency Response (UNMEER)—an organization tasked with coordinating the UN response to Ebola and the first time the UN had ever created a mission solely dedicated to a matter of international public health (Kamradt-Scott et al. 2015: 8). Outside of the UN system, numerous governments and non-governmental organizations mobilized to respond to the outbreak. Médecins Sans Frontières (MSF), known in English as Doctors Without Borders, took an early leading role in calling the world’s attention to the outbreak and in prompting WHO and UN to take a more aggressive response. MSF and other non-governmental organizations (NGOs) like Samaritan’s Purse had already been delivering significant levels of health care in the affected countries and provided a large portion of the on-the-ground medical treatment

Global Health Governance in International Society

in the affected countries (Henwood 2016: 18). The United States, United Kingdom, and China deployed military personnel to set up treatment centres and offer logistical support to transport materiel to the region (Kamradt-Scott et al. 2015). The US Centers for Disease Control and Prevention (CDC) redeployed its polio vaccination teams in Nigeria to work with that country’s government to provide contact tracing and implement programmes to stop Ebola’s spread when it appeared in Lagos (Osterholm and Olshaker 2017: 154). The Bill and Melinda Gates Foundation pledged $50 million to fight the outbreak, and Paul Allen, the co-founder of Microsoft, personally committed $100 million. Taken altogether, the response to this outbreak represented a massive undertaking that eventually helped to stop the largest recorded Ebola outbreak in history. The response to the 2014–16 Ebola outbreak was flawed in many ways, and the delays and problems allowed the virus to take hold in a significant way and increased the death toll. At the same time, and not in contradiction to the previous point, the international community clearly recognized that responding to cross-border health issues like Ebola is vital. It may fumble around, and it may make mistakes, but no one seriously argued that the international community did not have a vital stake in addressing the Ebola outbreak. The question was never whether the international community should respond; the question was always how the international community should respond. A wide variety of actors—intergovernmental organizations, developed states, developing states, non-governmental organizations, philanthropic organizations, and private business—came together to address a cross-border health challenge, even though it directly affected very few of them. They mobilized an unprecedented effort to raise the necessary funds. They found various ways to coordinate and cooperate. This does not imply that they did it perfectly or that the international community will avoid any future health crises, but the fact remains that these members of the international community did it because they viewed it as part of their obligation and responsibility to each other and the larger international project. The response to Ebola is emblematic of a larger change when it comes to global health. Over the course of a single generation, the international community has undergone a radical shift in its views on its collective obligation to address health on a global scale. Health has moved from the realm of technocratic, domestic politics to being a vital and important issue on the global political agenda. Rather than leaving health up to states to handle on their own, the international community has embraced a sense that it has a moral obligation and responsibility to respond to health issues, particularly those in low- and middle-income countries. This shift towards accepting the need to respond to global health concerns is both rhetorical and financial—and has (thus far) been maintained even in the face of the incredible economic 2

Introduction

issues and austerity policies that have faced high-income states since 2008. The Ebola outbreak is simply the latest manifestation of a movement towards recognizing the significance of global health that the international community has seen developing and growing since the late 1980s. These shifts in attitude and practice represent a wholesale change in the collective understanding of the importance and relevance of global health to the international community. The elevation of global health governance reflects a larger transformation within the international community. There is a growing recognition that there exists a sense of moral responsibility and obligation within international society. Actors have a responsibility to address those issues that seemingly may not directly affect them but present negative repercussions for the greater international community. This sense of moral responsibility and obligation is reflected in the ever-increasing importance of humanitarian intervention (Wheeler 2000), environmental protection (Falkner 2012), and freedom from hunger (Gonzalez-Pelaez 2005) for international society. It draws on and expands Vincent’s notion of basic subsistence rights to recognize a shift towards putting more teeth and institutional force into the recognition and realization of rights (Vincent 1986). This sense of moral responsibility and obligation does not necessarily have a formal structure in all cases, and there remain debates within international society over how to realize these ideas, but the underlying institution itself exists. Health, with its long history of innovative efforts to bring together a wide array of actors to address crossborder concerns, fits nicely within this larger framework. What explains this shift in the international community’s sense of obligation and the necessity of actuating an effective response? In this book, I argue what is most unique about global health governance in the contemporary era is that its diplomacy, initiatives, and commitments reflect its emergence as a secondary institution in support of a larger primary institution of moral responsibility within international society—a group of states with common and institutionalized interests and values bound by a set of common rules—as described by English School of international relations. This approach counteracts the pessimism and instrumentality of realism, incorporates a normative consideration that is lacking in liberalism, and offers a more explicitly normative framework than that offered by constructivism. Global health governance has emerged as an ethical project. The question is why, and this is where the English School is particularly well suited and useful. English School theorizing is neither myopically optimistic nor needlessly pessimistic. It acknowledges the shared interests in working together to achieve common goals while understanding that there exist limitations on the ability to satisfy those desires. It does not require a belief that states always act altruistically or that they always sacrifice their selfish interests, but rather offers an opportunity for understanding how 3

Global Health Governance in International Society

these sorts of common bonds can develop and be sustained even in instances when individualized interests are not at work. It is important to realize that the emergence of a secondary institution of international society is only part of the process. The members of the international society may share common ideas and rules, but that does not mean that those ideas and rules are correct or appropriate for the situation. They will change and adapt over time as their limitations become apparent. Traditional primary institutions described by the English School, like diplomacy and international law, have evolved over time in response to changes in the international system, past failures, and other problems, so it is entirely consistent to both criticize the ability of global health governance structures to respond to a problem and argue that this institution will evolve in response to these flaws. Indeed, we can argue that there exists a certain degree of counterfactual validity at work (Kratochwil and Ruggie 1986: 767)—the fact that members of international society are talking about the need to reform the global health governance system in light of its shortcomings is evidence that they believe such an institution exists, has value, and is worth preserving for the future. In the case of global health governance, its emergence as a secondary institution of international society reflects the burgeoning recognition of the importance of cooperation in order to achieve collective health goals. If states want to decrease the likelihood that they will face negative effects from the outbreak of infectious diseases and prevent future outbreaks from occurring, they must work together; no state can adequately address these concerns on its own. At the same time, though, these efforts to promote cooperation through global health governance challenge traditional notions of sovereignty because they expand the range of relevant actors who help implement global health strategies. Understanding the emergence of global health governance as an institution of international society while examining where its shortcomings exist is at the core of this book. The idea of an extensive global health governance architecture would have made little sense and had little purchase at earlier times. Global health was largely synonymous with WHO, but, as will be described over the course of the book, WHO now shares the global health space with a dizzying mixture of state and non-state actors. As a result, WHO’s status as the dominant actor within global health is part of a contentious debate. International society has shown a willingness to embrace a more expansive notion of global health and its governance as it recognized the relationships between globalization and the spread of illnesses, saw the need for fostering cooperation, and witnessed the failures that occurred when institutional responses and frameworks were inadequate to address problems like HIV/AIDS. The emergence of global health governance as a secondary institution of international society, though, does not imply perfect adoption. Institutional 4

Introduction

development is a process of various actors trying to tease out meanings, implications, and proper policies and implementing different organizations and strategies to realize these goals. It is an effort to bring a large number of actors together in a useful way. It is also an important and vital reminder that international society is not determinative; the existence of norms and values that encourage and promote collaboration on global health matters does not automatically translate into policies that actualize these norms. Changing norms and values enable new actions, but they do not automatically mandate that these actions will be embraced or implemented. It is the fact that actors recognize these failures and shortcomings, though, that demonstrates the existence of global health governance as an institution within international society. This book is unique in that it specifically seeks to engage the global health governance literature with international relations theory. To its detriment, the global health politics literature has engaged with the international relations theory literature sporadically and relatively superficially (for examples of engagement between global health politics and international relations theory, see Davies 2010; McInnes and Lee 2012; Price-Smith 2001; Youde 2005). This has impoverished the global health politics literature in two key ways. First, failing to engage with international relations theory contributes to the marginalization of global health within the larger political science and international relations literatures. The lack of engagement leads to an image of global health politics being more focused on the health side of the equation and largely removed from the political element. Global health becomes peripheral to understanding larger questions about how actors interact in the global arena and try to achieve common goals. Second, the global health politics literature lacks a firm foundation by not engaging with international relations theory in a more meaningful way. Without a theoretical framework, global health politics can become too rooted in the immediate—lacking the tools to put the immediate into a broader perspective that speaks to a larger audience and provides a historical context for present health crises and the range of available international political responses. An atheoretical approach privileges the problems and crises without offering the framework for understanding how and why the situation exists and how it might change in the future. International relations theory cannot predict the future or explain every instance of an event, but it does offer a useful heuristic for interpreting when and how the community of states and international agencies operate at the international level (Snyder 2009). At the same time, this book is not an uncritical endorsement of the English School. It demonstrates how engagement with global health governance reveals important theoretical oversights. To date, English School theorists have not consistently considered vital issues of international political economy, foreign 5

Global Health Governance in International Society

aid, and development. Its treatment of non-state actors, which have played an incredibly significant role in supporting the inclusion of global health on the international agenda and international relations more generally, remains fairly underdeveloped. If we want to appreciate how the international community has developed an obligation to respond to global health concerns, we need to develop sophisticated, nuanced representations of foreign aid and non-state actors. This will not only benefit our understanding of global health’s place on the international agenda, but also flesh out relatively neglected elements of English School theory. Finally, this book aims to show both the successes and failures of how global health governance has engaged with international society and vice versa. While the argument presented here sees this engagement as largely a positive arrangement reflected in changes like increased development assistance for health (DAH) over the past twenty-five years, larger-scale responses to global health emergencies, and an increasing number of actors involved in framing the diplomacy of global health governance, it is also worth highlighting some of the flaws in this current iteration of global health governance. These include the ambiguous role of China, disjunctures between the health conditions that cause the most death and illness and those that receive the most funding, and the difficulties in coordinating action between state and non-state actors engaged in global health governance. The argument presented here will be informative without being shortsighted, theoretically engaged without being too abstract, and will draw on case studies without losing sight of the overarching narrative. This book aims to make four key contributions. First, it will explicitly integrate the literatures on global health and international relations theory. Providing a firm theoretical grounding for the global health politics literature will enable a longer-term perspective on global health governance rather than focusing primarily on immediate crises. Second, it will engage with the existing literature on the English School while also trying to push its boundaries. Through a discussion of the role of DAH, it will make the case for the English School to engage more systematically with international political economy. By recognizing the role of non-state actors in realizing the ideals of global health governance, it will show the value of expanding the range of actors recognized as members of international society. By identifying global health governance as a secondary, rather than primary, institution, it will demonstrate both the need for the English School to engage more with the role of secondary institutions and highlight how primary and secondary institutions interact with one another. Third, it will trace how the current global health governance system emerged and has evolved over the years. Global health governance has dramatically changed over the past generation, but its origins go back to the mid-nineteenth 6

Introduction

century. To understand how and why the current global health governance institution came to be, it is imperative to recognize its evolution. Finally, this book shows the benefit to the English School in seriously engaging with secondary institutions and their role within international society. The English School has traditionally relegated secondary institutions to other theoretical traditions, assuming that they are simply the concrete manifestations of larger ideals. This book aims to show that secondary institutions play a significant independent role in international society and deserve sustained analytical attention in their own right.

Chapter Outline The book is divided into three main sections: understanding the English School and international society (Chapters 1 and 2); understanding global health governance (Chapters 3 and 4); and global health governance in action in international society (Chapters 5, 6, and 7). The first two chapters situate the book within the English School of international relations theory. Chapter 1 focuses on why English School theorizing is particularly relevant for understanding why and under what circumstances actors choose to contribute to coordinated international actions. Though it receives relatively little attention within the American international relations academy, English School theory has both a rich history and a nuanced understanding of the international environment. This makes it an ‘underexploited resource’, to use Buzan’s (2001) phrase, for understanding the emergence of complex systems like global health governance as an institution within international society. This chapter describes the foundations of the English School and highlights why this theory is of particular relevance for understanding the expansion and resilience of global health governance over the past generation. At the same time, this chapter expands upon the traditional notions of the English School, pushing it to modernize in order to understand how the international environment has shifted over the past half-century. In particular, the chapter calls attention to the need to address the role of non-state actors as potential members of or contributors to international society and the value of explicitly incorporating political economy into English School theorizing. Chapter 2 digs into English School theory more intensely by discussing the role of different types of institutions and their effects on international society. Since this book takes the position that global health governance is a secondary institution within international society and operates in conjunction with an emergent primary institution of moral responsibility and obligation, it is of utmost importance to explain the differences between primary and secondary institutions. This chapter also holds a challenge for the English School to take 7

Global Health Governance in International Society

secondary institutions more seriously. Too often, secondary institutions are dismissed simply as formal organizations or international regimes—which are then, in turn, consigned to the realm of regime theory or seen as too far removed from the English School’s central concerns. This chapter argues that such an approach impoverishes the English School and prevents us from recognizing the role that secondary institutions actually play in international society. Far from being just formal organizations, they have their own constitutive powers and help us to understand international society. Chapter 3 begins to focus on global health governance as an institution. In particular, this chapter looks at how global health governance has emerged over time. While global health governance has become prominent over the past generation, it grew out of an evolutionary process that we can trace back to fears about the international spread of disease in the 1800s. Tracing these changes over time not only helps us to understand the contours of the current system, but it also provides a window for seeing where efforts to instantiate global health governance and its normative precepts more firmly within international society have not worked. This chapter pays attention to seven key moments or processes that help us to understand the evolution of global health governance: the International Sanitary Conferences; the League of Nations Health Office; the World Health Organization; the Health for All by 2000 movement; the International Health Regulations; the Global Fund to Fight AIDS, Tuberculosis, and Malaria; and the Bill and Melinda Gates Foundation. While Chapter 3 focuses primarily on the evolution of global health governance, Chapter 4 pays more attention to its contemporary manifestation. This chapter will discuss the current state of the global health governance framework—who the important actors are, how the various governance structures have changed over the past twenty-five years, and what the fundamental beliefs and attitudes of the global health governance system are. In particular, the chapter will discuss the relationship between state-based and non-state actors, as well as public versus private actors. International organizations play an important role within international society, facilitating activity that states cannot or will not do in a bilateral fashion. By drawing on financial, personnel, and information resources from a variety of states, international organizations can foster the sort of collective action that is necessary in order to bring desired goals to fruition. This chapter highlights five key players within contemporary global health governance: states; WHO; multilateral funding agencies; public–private partnerships; and private philanthropic organizations. Chapters 5, 6, and 7 provide an opportunity to look at areas that challenge global health governance and raise questions about its current form and future orientations. Chapter 5 looks at the incredible growth in DAH from the 8

Introduction

international society since the early 1990s. The funds devoted to global health have increased nearly 600 per cent in twenty-five years. More remarkably, these funds have remained surprisingly stable even in the face of the global economic recession and its negative effects on foreign aid in general. It does not mean that the amount of funding has been adequate or necessarily kept pace with changing needs, but its stability in the face of economic and political pressures makes it harder to call global health aid discretionary or a budgetary afterthought. DAH also illustrates the expansion of actors playing significant roles in global health governance. No longer solely the province of traditional donor states, global health governance is increasingly funded by intergovernmental organizations, lending agencies, PPPs, and private philanthropic organizations. This expansion opens up new possibilities, but also comes with its own complications. Chapter 6 examines how international society responded to the Ebola outbreak in West Africa. From the first official notification of the outbreak in March 2014 to the official end of the PHEIC for Ebola just over two years later, international society’s response has come under significant criticism. Much of the criticism has focused on the role and operations of the WHO. In many ways, the response to Ebola mirrors many of the larger questions around the successes and failures of global health governance within the international system. On the one hand, the international community recognized the need to respond to the Ebola outbreak, contributing large sums of money and mobilizing resources on a scale never before seen. On the other hand, WHO dithered in its response, the international community did not have quick and easy access to needed funding and personnel, and few states paid attention to the warnings coming from various NGOs that were providing on-the-ground medical services. WHO lacks the budgetary flexibility to shift funds to address an outbreak, and it has no reserve funds to implement an immediate response. Further, while many of the funds pledged deal with the immediate problems that gave rise to the Ebola outbreak in the first place, there is less attention paid to strengthening health care systems and training additional health care workers—longer-term strategies that are necessary for stopping future infectious disease epidemics sooner. This experience shows that international society’s recognition of the importance and value of working together to address global health issues is emerging, but also that it has not yet fully consolidated the rules, norms, and common standards within this institution. It is still a work in progress rather than a fully realized system. Chapter 7 draws on earlier debates in the English School conception of international society and questions of whether it could incorporate nonWestern states. In this case, the analysis concentrates on China and its role within the larger global health governance system. China plays an interesting role in understanding the emergence of global health governance within 9

Global Health Governance in International Society

international society. In many ways, it embodies the unresolved nature of this international society. China has sought to take a more active role in global governance activities, including those focused on health. For example, it has long deployed medical teams to African states to provide primary health care and access to pharmaceuticals. Despite this apparent interest in engaging with global health governance, the Chinese government has also exhibited a reluctance to work through existing multilateral channels. Instead of actively engaging with multilateral health organizations on a consistent basis, it generally directs its global health funding through bilateral channels. China’s actions towards global health aid highlight both the recognition of the importance of a collective approach to adequately address these issues and the concerns about giving up too much control to international organizations that it has argued are too Western-centric. This chapter will show how China’s health diplomacy operations work and how its approach raises concerns in other parts of this emergent international society institution. It also points to the enduring nature of long-standing concerns about how, why, and whether international society and its institutions expand to non-Western states. Finally, the Conclusion summarizes the arguments made throughout the book and reinforces the analytical usefulness of grounding an analysis of global health governance within an English School framework. It also examines what an understanding of global health governance as a secondary institution related to a primary institution of moral responsibility and obligation may tell us about the future directions for global health governance.

10

1 The English School and the Emergence of International Society

The contemporary global health governance system, while by no means perfect, facilitates international cooperation to achieve the common goal of addressing cross-border health concerns. The actors active within global health governance in many ways share common outlooks on how to address their concerns and tend to abide by a shared set of principles, ideas, and norms in their operations with each other and with recipient states. States may not always act optimally; they may pursue ill-advised policies, underfund organizations charged with carrying out the work of global health governance, or respond too slowly. Despite these shortcomings, it is impossible to deny that the institution of global health governance exists. Indeed, if anything, the global health governance system has become further instantiated within the international community since the early 1990s. What explains how this system has emerged, and what explains its incredible growth and resilience over the past generation? I argue that these changes within global health governance are evidence of its emergence as a secondary institution within international society as described by the English School of international relations. This secondary institution of global health governance helps support an emergent primary institution of moral responsibility and obligation that focuses on issues like humanitarian intervention, environmental protection, the alleviation of suffering, and freedom from hunger. These are issues that English School scholars have highlighted as increasingly foundational for international society, and the idea of a primary institution of moral responsibility and obligation brings them together in a single concept. At the same time, the emergence of global health governance within international society calls attention to some of the shortcomings within current English School theorizing about international society. English School theory has traditionally paid little attention to issues of international political economy or the role of non-state actors, but the global health governance system

Global Health Governance in International Society

demonstrates the vitality of these issues for understanding the contours of international action. It has also given relatively short shrift to exploring and understanding secondary institutions. Therefore, addressing global health governance within international society allows us to expand the English School’s horizons. Before delving too far into theory, it is important to emphasize that it is entirely consistent to argue both that the emergence of global health governance as a secondary institution within international society constitutes a set of common expectations and norms around which states have generally converged and that these rules, norms, and expectations are still in flux and unresolved. The existence of an institution within international society does not necessarily require the existence of a set of settled and optimal practices and expectations, nor does it suggest that a given institution will necessarily generate optimal policy decisions in all instances. Institutions change and evolve over time, and global health governance is no different. It is wholly appropriate to identify global health governance as a secondary institution within international society and criticize the operation of that same institution. This chapter begins by describing the broad outlines of the English School. It then examines the nature of international society and its place within English School theorizing. The next section examines some of the key debates within our understanding of what international society entails, particularly the divide between the pluralists and the solidarists. Finally, the chapter details areas which English School theorizing needs to better address in order to understand the changing nature of the international system in the contemporary era.

Core Beliefs of the English School and International Society Since its emergence as a relatively distinct approach in the 1950s and 1960s, the English School has occupied a unique place within international relations theory. It largely originated out of the interactions and debates that occurred among members of the British Committee on the Theory of International Politics, such as Herbert Butterfield, Martin Wight, Hedley Bull, and Adam Watson (see Dunne 1998). Its early proponents laid out a theoretical framework in which sovereign states come together to create a society that helps provide order and justice within the international realm in the face of anarchy. Countering the arguments of classical authors in both the realist and liberal traditions, the English School posits that international relations is not a realm of unrelenting danger as posited by Hobbes, but neither is it as utopian as Kant would suggest. Instead, the English School’s progenitors assert that we must try to understand the rules, norms, values, and institutions that have emerged and 12

The English School and the Emergence of International Society

govern international interactions. As such, this orientation gives the English School a normative dimension missing from many other international relations theories (Buzan 2001). Despite some debate in the early 1980s that the paradigm had outlived its usefulness ( Jones 1981), the English School has experienced a renaissance of scholarly interest and influence since the 1990s. The English School has played a key role in refining and shaping the debate on many of the core concepts in modern international relations, such as human rights (Vincent 1986), humanitarian intervention (Bellamy 2011; Wheeler 2000), diplomacy (Sharp 2009; Watson 1982), and evolving notions of sovereignty (Dunne 2001; Jackson 1993). The English School focuses its analysis on three key concepts. The first, international system, is about power politics among states, and roughly parallels the tenets of realism and neorealism. The second, international society, emphasizes mutual interests among states and the maintenance of shared rules, norms, and institutions among states. The third, world society, transcends the state and incorporates individuals and non-state actors into the creation of a global societal identity based on shared universal values (Buzan 2014: 12–14). These three dimensions do not stand in opposition to each other; all three simultaneously coexist and interplay with each other. The issue for analysis is the relative strength of each in relation to the others at a particular time and place. By and large, the English School has concentrated its attention on international society. Bull offers the canonical definition of international society, describing it as emerging when ‘a group of states, conscious of certain common interests and common values, form a society in the sense that they conceive themselves to be bound by a common set of rules in their relations with one another, and share in the working of common institutions’ (Bull 1995: 13). Jackson builds upon Bull’s definition and describes international society as: A notion of states as freely consenting adults who form international society by making treaties, observing common customs and usages, attending conferences, founding organizations, and engaging in other bilateral and multilateral activities which aim at moderating their relations and providing goods in common. ( Jackson 1993: 166)

Bull’s and Jackson’s definitions flesh out this potentially amorphous notion of international society into something more easily understood. They show how international society’s primary institutions consist of fundamental, durable practices that have evolved over time and are constitutive of both the relevant actors and their legitimate relations with each other (Little 2007). In other words, international society makes interactions among states possible and gives them meaning. Interactions are not reducible to strategic calculations; they 13

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reflect common interests, rules, and values. Dunne notes, ‘International society exists as a social fact. Like all social structures, it is unobservable but its effects are real’ (Dunne 2001: 89; emphasis added). Determining who is a member of international society can pose some challenges. There is no formal application process; international society is not the same as an intergovernmental organization. Instead, membership emerges through a process of mutual recognition and demonstrated adherence to a set of common beliefs and ideas. In their definition of international society, Bull and Watson emphasize that the members engage in ‘dialogue and common consent rules’ as the basis for their relationships because they ‘recognise their common interest in maintaining these arrangements’ (Bull and Watson 1984b: 1). Thus, it is through participation in the institutions and practices of international society that states acknowledge one another as members. ‘Recognition is the first step in the construction of an international society’ (Dunne 2011: 735). While this process opens the possibility for many, if not all, states to be a part of international society, the historical record shows that international society has restricted its recognition to certain states and peoples. The nineteenth century’s ‘standard of civilization’ deemed particular internal governance structures that were common in European states as prerequisites for membership in international society. As a result, China and other non-European states were excluded from international society and the benefits of working through its institutions (Gong 1984). This does not mean, for example, that China and European states did not interact with one another during this time. Rather, it means that these interactions were based on strategic and economic calculations rather than on the basis of a belief in their shared commonalities (Dunne 2011). Shared interests are central to the emergence and sustenance of international society, and those shared interests emerge through a process of socialization. The common beliefs and values that unite international society neither appear out of thin air, nor are they explicitly constructed by a powerful hegemon. Instead, they evolve over time, and states become socialized to accept and abide by them. The members of international society eventually make these shared beliefs a part of their own understandings of the world (Alderson 2001). These norms become expressions of a moral standard imbued throughout international society. This is not to say that there is no contestation among states about the exact meaning or form of these norms or that international society is one of constant harmony. What it does mean, though, is that common interests are essential to international society’s construction and maintenance. While there may be differences in how to understand or apply the specific normative elements of international society, the members largely agree to the general outlines. Dunne explains:

14

The English School and the Emergence of International Society International society can signify the presence of intricate patterns of social interaction, evident in the balance of power in their general fidelity to the rules of the game. This does not mean that states will always act in accordance with agreed rules and convention, only that this is the regular pattern and not the exception. (Dunne 2005: 66)

International society is thus fundamentally constituted by rule-governed actions, and its members are socialized to understand what actions are legitimate within the norms, rules, and values that have evolved within that society (Wheeler 2000: 21–5). Statecraft, then, is inherently a realm of social action, and socialization is a vital part of statecraft. Jackson emphasizes that discourse, which is by its very nature relational and social, is an essential property of political activity. International relations exist only in relations to the emergence of some sort of recognition of ‘the other’ (Jackson 2003: 10–15). By the same token, international society is not external to states. Through the recognition of ‘the other’ and engagement with it, states actively create international society, are constitutive of it, and socialized into it (Linklater and Suganami 2005: 53). Through these interactions, international society injects a normative dimension into international relations. International society is more than just an analytical category; it is also a tool for promoting the betterment of humanity and alleviating suffering. Buzan describes the English School as ‘broadly meliorist, thinking that an imperfect world can be made better by human effort’, though he stresses that this does not mean that the English School is naively utopian or idealist in its orientation (Buzan 2014: 30). Instead, this normative dimension expresses itself at least partially through the importance that international society attaches to interdependence (Brown 1995). This connection is evident in English School writing on responding to international needs. Suganami harkens back to Vincent’s work in the 1980s to argue that one of the most fundamental purposes of international society is to respond to those who are incapable of providing for their own subsistence (Suganami 2005: 38–9; Vincent 1986). Wheeler traces how shifts within international society and its constitutive shared ideas and values gave rise to the legitimation of humanitarian intervention and violating state sovereignty in the name of stopping human suffering (Wheeler 2000). Responsibility to Protect (R2P), the idea that states have a moral and legal responsibility to prevent atrocities within their borders and that the international community has an obligation to use appropriate means to protect peoples from atrocities, draws much of its intellectual heritage from English School ideas about international society (Bellamy 2011). This commitment to normative action and response gives rise to a specific form of ethics that appreciates the central importance of states actively taking

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steps to remedy problems within the international community. Jackson writes, ‘International ethics and world politics are not separate spheres; they are different aspects of the same sphere’ ( Jackson 2003: 6). As a result, international relations is fundamentally about moral issues and how actors respond (or fail to respond) to situations. Linklater and Suganami largely equate international relations with good international citizenship. Foreign policy is more than maximizing strategic interests; it is a ‘tool to promote the moral ideal of the unity of humankind without jeopardizing international order’ (Linklater and Suganami 2005: 232). Jackson describes this as part of a global covenant, giving world politics some semblance of order through respect for a common code of conduct and the importance of promoting global cooperation. This understanding stresses the importance of marshalling a response to international failings or inequities. International society’s ethical obligations provide a space for recognizing that states frequently take a more holistic view of who benefits from foreign policy decisions and how they accrue such benefits. This is not the same as saying that states are inherently altruistic or always other-thinking; rather, it acknowledges how interdependence and mutuality can alter a state’s strategic foreign policy calculus. To that end, combatting an infectious disease outbreak in another country may have some strategic calculation behind it, but it is also emblematic of the understanding that taking steps to reduce the suffering in another state is advantageous to all. Global health governance and other humanitarian-oriented norms add to our understanding of international society because they ‘may give an indication of where to look to discern the directions that international society might take as we move into the twenty-first century’ (Jackson 2003: 17).

English School Normativity in Action: Pluralism and Solidarism International society contains two key imperatives: order and justice. The members of international society desire both order and justice, but there exists a possible tension between them which colours the relationship among those members. Pluralism and solidarism provide two different understandings of the relative priority international society should place on the rights of sovereign states as opposed to the value of promoting particular rights even when they impinge upon absolute state sovereignty. While pluralism and solidarism have frequently been conceptualized as opposite positions, it is better to consider them as representing two ends of a spectrum. Elements of both constantly coexist within any manifestation of international society, so it is more fruitful to examine the relative balance between them at a given moment. Pluralism emphasizes a state-centric model that prioritizes international order. At its core, pluralism is about responsibly managing and maintaining 16

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a diverse international society ( Jackson 1990). It focuses on norms that facilitate coexistence and privileges state sovereignty. International society is made up of a large number of diverse practices and ideologies. To that end, it is international society’s duty to provide a framework that can find arrangements that allow for recognition of this diversity while still encouraging a general ethos of coexistence. To this degree, Buzan calls it ‘the more conservative side’ of English School theory (Buzan 2014: 89). For the pluralists, it is precisely this relatively limited vision of international society that allows diversity to flourish. So long as states have differing interests and values, pluralism provides international society the space to maintain that diversity in the face of totalizing universalist ideologies that flatten or ignore such differences and thus introduce the very conflict that international society seeks to avoid (Mayall 2000b: 14). In this formulation, aggressively promoting particular values as being universal, like human rights, necessitates running roughshod over this diversity. Avoiding an overly optimistic or idealistic vision of international society, pluralists tend to take a more pragmatic approach. Mayall, for example, argues that we live in a pluralist world, regardless of whether we like it or not, so it is better to accept the system as it is if there is to be any progress (Mayall 2000b). Sovereignty is the bedrock principle of a pluralist international society, and more expansive visions that emphasize universal ideals necessarily threaten sovereignty and introduce instability and conflict into the world ( James 1999). While we may hold aspirations for a grander vision of what international society can do, a more pragmatic conceptualization of the limits of international society helps to maintain the system. A more expansive vision requires assuming a higher degree of agreement about core values within international society than actually exists and instead ‘carries the danger that it will be subversive of coexistence among states’ (Bull 1984a: 13). The facts of international politics and how states behave work against the creation of a more expansive international society. Pluralism argues that states cannot agree on common universal values, but they can at least share a commitment to a live-and-let-live ethos. Pluralism’s state-centrism, its advocates posit, simply reflects political realities. International law is positive law and therefore only made and enforced by states, and it is the state that provides the necessary elements that allow humans to flourish. A secure state provides the foundation for human achievement, so it is necessary to put the state at the centre of analysis. This is not to deny that other sources could allow for people to realize their goals and aspirations, but state sovereignty is unique for its ability to transcend other issues and facilitate minimal levels of coexistence that make some notion of international life possible (Jackson 2003: 206–7). Solidarism takes a broader vision of international society’s possibilities. If pluralism is associated with order and with how international society is, 17

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solidarism is associated with justice and with how international society ought to be. It lends more credence to the development of a society that allows for emphasizing human rights and allowing for intervention. It views ‘humanity [as] one, and that the task of diplomacy is to translate this latent or immanent solidarity of interests and values into reality’ (Mayall 2000b: 14). It offers the possibility of moving beyond a state-centric view to bring together states, nonstate actors, and individuals as significant players. The ethical issues that vex international society necessarily transcend borders, according to solidarists, so international society must move beyond mere coexistence towards a conception that reflects shared normative goals. In this way, solidarists argue, international society can actually provide for both order and justice. Buzan writes, ‘Order cannot work without some underpinning of justice in which interstate society takes account of the needs and rights of its citizens’ (Buzan 2014: 114). Solidarism, according to Bull, overcomes its state-centrism by emphasizing the interests of the social whole over those of independent, sovereign states. This broader vision of whose interests are prioritized also opens a space for a wider range of actors to get involved. If we do not limit our understandings of international society to states, then it follows that non-state actors could have a role to play in formulating and implementing the normative vision embodied within international society (Bull 1995). As such, non-state actors can contribute to international society’s ability to address important issues in a positive way without taking away from the power and authority of states. The solidarist perspective does not automatically obviate the importance of sovereignty. Instead, it puts sovereignty within its larger international context to understand how it currently operates and how that operation changes over time. Vincent argues that sovereignty is a right that international society grants to its members. As such, that same international society can make sovereignty conditional on upholding and maintaining some minimal level of adherence to certain normative precepts. This formulation thus circumvents the idea that there is an inherent conflict between sovereignty and broader normative content to international society by making them conditional upon each other. Instead, the recognition of sovereignty can provide the lowest common denominator from which international society can build up to agreements on other issues. From such a starting point, Vincent suggests that international society can gradually build upon this foundation to embrace more solidarist positions over time (Vincent 1986: 150–2). Dunne describes this approach as one of practical ethics for its pragmatic approach towards incorporating broader goals into international society (Dunne 1995). This conception of international society broadens the realm of primary institutions that may operate. Increased recognition of international human rights standards and attaching the responsibility for their protection to states is emblematic of a shift—albeit an incomplete one—towards a more 18

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solidarist understanding (Clark 2007; Welsh 2011). The promotion of democracy and democratic values has also achieved some degree of legitimacy in international society, particularly through the activities of international non-governmental organizations (NGOs) (Mayall 2000a). Buzan suggests that environmental stewardship may also be on its way to becoming a primary institution of solidarism, though he acknowledges that this remains contested (Buzan 2014: 161–3). Falkner shares this line of reasoning, arguing that a sense of environmental responsibility has affected other existent primary institutions, but that this rhetoric has thus far outpaced action (Falkner 2012). Based on these conceptions of pluralism and solidarism, it becomes clear that they are not actually in opposition to one another. Rather, they are points along the same spectrum. Envisioning pluralism and solidarism as polar opposites weakens the explanatory power of international society and English School theorizing in general. Understanding them as points on a spectrum, though, allows pluralism and solidarism to ‘reinforce the position of international society as the via media between state-centric realism and cosmopolitan world society’ (Buzan 2004: 50). Weinert concurs, ‘Determining whether contemporary international society, as a whole, is either pluralist or solidarist remains a fraught, if not futile, exercise’ (Weinert 2011: 21). Rather than being mutually exclusive, it is more accurate and theoretically useful to think of pluralism and solidarism as operating at the micro level to illustrate larger ideas about the nature of commitments to and ethical possibilities within particular issues (Weinert 2011: 23–4, 35). This approach allows us to understand variations in how states accept broad principles and how those principles have regulative effects on state practices (Weinert 2011: 36–8). Understanding pluralism and solidarism as points along a spectrum gives us reasons to believe that global health governance is emerging as a secondary institution within international society. For example, while spending on development assistance for health (DAH) is increasing and being driven by a wider variety of actors like the Bill and Melinda Gates Foundation (BMGF), the majority of funds still come from sovereign states. There exists a certain expectation that states will contribute something to the creation and maintenance of international society—even while their individual sovereignty is respected. States can be broadly committed to the principles of global health governance and its importance as a primary institution as an overarching idea, but employ differing logics to motivate the policy actions undertaken in response to that idea. Varying levels of DAH, for example, need not be taken as prima facie evidence that states no longer believe in global health governance. By the same token, the emergence of non-state actors into this space is not a sign of states ceding their traditional responsibility or of the impending collapse of international society. 19

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Indeed, building upon Weinert’s argument, we can recognize how an institution like global health governance embodies both pluralist and solidarist elements. Pluralism and solidarism in and of themselves do not direct international society towards any specific action (or inaction). Weinert demonstrates this reality through his examination of human security. By considering the interplay between the state and the individual, he uncovers that solidarism need not imply a radical overhaul of international society to realize human security’s potentials. Further, he finds that pluralism contains opportunities for states to undertake progressive actions in order to protect individuals from a wide range of insecurities (Weinert 2011: 24). Similarly, Gonzalez-Pelaez and Buzan describe how Vincent’s basic rights initiative ‘bridge[s] the pluralist demands of international society (sovereignty and nonintervention) with the humankind that joins individuals across frontiers’ (Gonzalez-Pelaez and Buzan 2003: 322). Establishing a core of basic rights could create a common culture and set a minimum threshold below which standards should not drop, yet still respect state sovereignty. In this way, Vincent’s efforts respect and seek to strengthen the legitimacy of sovereignty by pursuing a seemingly solidarist effort (Gonzalez-Pelaez 2005: 2–20). This dynamic thus opens significant opportunities for international action, especially when it comes to issues of moral responsibility and protection of others beyond national borders. Instead of assuming that pluralism closes off all but the most minimal range of international action or that solidarism obviates the existence of sovereignty, both perspectives work in tandem with each other to facilitate international action. Addressing cross-border health concerns necessarily means that actors must take some measure of the needs of others, but those same actors can still see the value in acting in order to promote their own interests. Stopping the spread of Ebola in West Africa, for example, is not therefore only good because it helps people living in that region, but also because it helps a state’s own citizens by decreasing the likelihood they will face the disease themselves. At the same time, this dynamic helps us to understand why problems may arise in the global health governance system.

Pushing the Boundaries of International Society English School theorizing provides a useful heuristic for considering how and why global health governance has developed and grown so greatly since the early 1990s. States have been socialized to recognize that good international citizenship includes cooperating internationally to establish and maintain institutions and practices that address cross-border health concerns. International society recognizes that health is more than a simple technocratic 20

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exercise and instead occupies an important place on the international community’s political agenda. While debates remain over appropriate funding levels and the responsiveness of various institutions to disease outbreaks and other health issues, there is evidence of the emergence of an institution within international society that shares a commitment to global health governance and sees it as a constitutive part of what good international citizens should do. Supporting global health governance has a normative, ethical dimension to it, and the international community recognizes the value and importance of responding to global health problems and inequities that exist in other countries. English School theorizing can be a useful tool for understanding these changes, but these same changes also call attention to the need to adapt some English School theorizing. In particular, the preceding highlights the importance of two substantive changes in the English School: a broadening of actors who potentially qualify for membership in international society, and a need to incorporate international political economy and foreign aid into the English School’s analytical framework. These issues are both key to understanding the evolution and operation of global health governance as an institution of international society.

Expanding International Society’s Potential Membership Non-state actors are absolutely vital for understanding contemporary global health governance, but English School theorizing about international society pays little attention to this group of actors. The importance of non-state actors is not unique to global health governance, but is instead a feature of contemporary global politics. By the same token, the failure of the English School to consider the role of non-state actors goes beyond its considerations of global health governance and instead reflects a more general failure to appreciate how non-state actors have come to play an important role in contemporary international society. English School ideas about international society emerged at a time when states were the primary international actors, so an exclusive focus on them may have made a certain degree of sense. Since the midtwentieth century, though, non-state actors have become increasingly prominent within international society and thus significantly influence its continued operation. Rather than being emblematic of the displacement of the sovereign state, the growth of intergovernmental organizations, NGOs, and private actors as relevant players within international society shows how an expanded understanding of relevant actors provides a more nuanced appreciation of the dynamics of modern international politics. Traditionally, English School theorists have restricted membership within international society to states. Non-state actors, be they NGOs, transnational 21

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activists, individuals, or intergovernmental organizations, are generally relegated to world, but not international, society (Buzan 2001). Reus-Smit justifies this exclusion by arguing that non-state actors lack the power to fundamentally alter the principles and dynamics within a society of sovereign states. Furthermore, non-state actors cannot displace the primacy of the nation-state as a political organization, so they deserve to be understood as subservient (Reus-Smit 2005: 90). Indeed, international society has tended to focus not just on states, but rather on advanced industrialized liberal democratic states (Brown 1995). If non-state actors hold any sway within international society, they acquire that status only when states grant it to them (Buzan 2005: 127). The historical record does show, though, that nonstate actors can be accorded the mutual recognition that defines membership within international society depending on the norms and shared understandings of that time. These include the Catholic Church and private trading companies during the imperial era (Dunne 2011). Instead of being part of international society, non-state actors are relegated to the realm of world society—the English School’s conception of a global social identity that is in coexistence with international society and encompasses ‘the totality of global social interaction’ (Bull 1995: 269). World society’s idea of a universal shared identity necessarily transcends the state and the nation-state system (Buzan 2001). Transnational actors, intergovernmental organizations, and other non-state actors play an additive role within international relations, but they do not replace the primacy of the state as a political institution (Buzan 2004: 35–8). Bull argues that transnational actors’ relationships with each other and other non-state actors are fundamentally different from those states have with each other (Bull 1995: 268–9). Clark identifies international society as ‘the realm of the governmental and the official’, while world society is ‘the realm of the individual, of the non-official group or movement, and of the transnational network of non-governmental agents’ (Clark 2007: 6). Buzan acknowledges that nonstate actors have a role to play and that their interactions with states are important, but he wants to preserve them as distinct categories. Transnational actors, he argues, can be active participants in international society, but they cannot be members because there is something special and unique about the state as a political actor (Buzan 2004: 88). Jackson takes this line of argumentation further, describing non-state actors like international organizations as significant auxiliaries of international society. While he maintains that they lack the power to operate independently of states and are therefore subordinate to them, he recognizes that civil society does not necessarily displace the role of the state ( Jackson 2003: 105–11). As states and non-state actors work together on an increasing array of issues and through a growing number of channels, maintaining the strict separation 22

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between them and their roles within international society becomes even more difficult. To understand the traditional strict division within the English School between international society (the realm of states) and world society (the realm of non-state actors), it is important to place the theorizing within its historical context. The English School emerged in the 1950s and 1960s among scholars who had lived through the experiences of the interwar period and World War II. The School’s progenitors drew on their lived experiences as a way of crafting a unique understanding of international relations (Dunne 1998). In particular, the interwar period seems to have played an important role in shaping the division between international and world societies. Clark writes that, during the interwar period: World society stood for a political ideal to be promoted, and was usually juxtaposed to, and contrasted against, the vicious and disruptive behaviour of the state system. Typically, world society was extolled as the wave of the future. (Clark 2007: 22)

The interwar period was such a time of idealism that the Kellogg–Briand Pact went so far as to outlaw war itself. In this line of thinking, the old system had caused what led to the Great War, so the obvious solution was to deny its centrality in international relations. There was a deliberate and conscious effort to move beyond the old state system, with the ultimate endpoint of making war unthinkable. This notion of world society—based on the idea that it was an improvement on the previously existing international society— perfectly embodied the idealism of the time and allowed non-state actors to achieve a level of parity with states in terms of their import for crafting policy throughout the world. The grand schemes and ideals of the interwar period obviously failed, and the world again plunged into war. What the members of the British Committee appear to have learned from the interwar period is that states are far and away the most important actors in international relations. They did not deny the existence of other actors, but they relegated them to a peripheral status—until and unless world society came to fruition with all of its attendant idealism, shared global consciousness, and common worldwide identity (Buzan 2014: 13). World society was thus generally equated with some sort of cosmopolitan ideal or even a world polity (Clark 2007: 24–7). This had the practical effect of reducing non-state actors to a tertiary role until some far future era. This is not to argue that the English School was unique in asserting the primacy of states. Given the specificity with which we can trace the emergence of the English School as a distinct framework within international relations, though, it is all the more apparent how the experiences of the interwar period coloured the tripartite division between the international system, international society, and world society within this theoretical framework. 23

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English School theorizing about international and world society has created a problematic and ill-fitting dichotomy. International society is solely the realm of states and represents a common set of behavioural standards while recognizing the enduring diversity of states. World society encompasses non-state actors and epitomizes the triumph of a universal worldwide identity that essentially creates a single cosmopolitan standard. This scenario renders power as a zero-sum game; the growth of non-state actors necessarily entails the diminution of state power and eclipsing the state as a meaningful centre of politics. Missing from this construction is an intermediate ground—one in which non-state actors could both play a useful and significant role in establishing and maintaining normative behavioural standards without requiring a sole cosmopolitan identity. It does not logically follow that an expansion of the realm of international society eliminates the continued existence of multiple identities. Membership in international society means embracing certain normative precepts while still maintaining a range of identities. If this dynamic operates across a wide range of states, it is not clear why it could not also embrace non-state actors. Further, it does not follow that the growth of non-state actors’ power means that states must necessarily lose power unless we define power and influence within international society as a highly finite resource. Nothing else in theorizing about international society makes this sort of argument. If the growth of international society entailed the loss of power and influence for others, then we would expect states to actively thwart any efforts by others to join its ranks. Instead, the historical record suggests that power and influence are fungible resources, and that the expansion of international society effectively increases its ability to respond to crises, emergencies, and situations. Maintaining a strict division between states and non-state actors is becoming increasingly complicated and difficult, which has led some scholars to push back against the traditional distinctions. Clark writes extensively about how the dividing lines between international and world societies are increasingly fuzzy as the two progressively overlap with each other: In between a continuingly exclusive state membership, and the final dissolution of international society, is to be found an accommodation between international and world society whereby the mutuality of their reciprocal claims is recognised. This may betoken a partial merger between the two societies, as against any putative dissolution of international society. (Clark 2007: 10)

Clark’s argument points to the difficulties in trying to maintain a strict separation between the state-exclusive realm and the realm of recognizing that nonstate actors are worthwhile actors in their own right within the transnational political sphere. Rather than being a sign of analytical sloppiness, Clark’s willingness to envision a political arena in which both state and non-state 24

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actors collaborate to act on normative ideals is a recognition of the changing nature of international politics in the contemporary era. While Clark may be among the most progressive English School theorists when it comes to recognizing the intersection of state and non-state actors, his is not a lone voice. Linklater and Suganami identify foreign policy’s ultimate aim as improving the international community to satisfy a diversity of interests with a growing cast of actors. The expansion of international society may make consensus more difficult to achieve, but they still consider it a valuable and achievable goal (Linklater and Suganami 2005). Buzan acknowledges that transnational actors and intergovernmental organizations are active participants in international society and that their contributions are additive rather than replacing of state power, though he posits that their participation in international society does not make them members of international society (Buzan 2004: 119). Even within this framework, though, he notes, ‘For now, and for some decades to come, the interesting question is about how the state and non-state worlds do and will interact with each other’ (Buzan 2004: 88). Bellamy and McDonald, in calling for the English School to engage in a more meaningful dialogue with security studies, emphasize that the realization of human security depends crucially upon engagement with non-state actors. While they do not necessarily make an explicit argument about expanding international society to include non-state actors, their ideas lend credence to the notion that non-state actors are relevant international actors in their own right (Bellamy and McDonald 2004). Non-state actors are also important for adding new issues to international society’s political agenda. Foote convincingly argues, ‘Human rights, the environment, the accountability of institutions, among other matters that impinge on order and justice questions, owe their prominence in part to the concerns that state governments have been articulating, but also to the activities of non-state bodies’ (Foote 2003: 8). What is particularly important about Foote’s argument is that she does not set state and non-state actors in opposition to one another; rather, they play complementary roles, and the involvement of one group does not entail the automatic diminution of the other. Expanding the realm of actors relevant for international society’s operation resonates with Hurrell’s idea of complex governance existing beyond the state (Hurrell 2007). Interstate governance forums, such as international tribunals, regional supranational organizations like the European Union, and cross-border regulatory bodies, are proliferating. Global civil society is emerging as both a regulative ideal and an institutional framework that is changing the practice of politics within the international arena. Even the market, both as a venue for allocating resources and for resolving social conflicts, is emerging as a potentially powerful actor in its own right. The nature of international relations has fundamentally changed since Hedley Bull’s day to allow for (though not require) 25

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a consideration of additional actors who could play a significant role in understanding how international society operates and the values that it embodies. The idea that international society could include non-state actors as members is not the same as saying that international society must include them or that non-state actors have replaced the state as a locus of power within the international sphere. Indeed, it would be wrong to overly diminish the role of states in international society; regardless of changes that may have occurred over the past fifty years, states remain the dominant actors within international society. The increase in actors involved in any issue within international society may not necessarily alter the underlying processes that give rise to the norms, values, and expectations that emerge within international society. The range of non-state actors is so incredibly vast, and many of them would have no connection to issues related to DAH. That said, there clearly are some non-state actors who play vital, determinative roles. How can we speak meaningfully about the global health agenda without including private philanthropies or NGOs? Trying to discuss the emergent normative behaviours in response to global health needs without including these non-state actors— who both engage in funding and help direct the issue agenda for global health—is necessarily incomplete and fails to give a comprehensive view of the active international society. Bull allows for, and arguably calls for, the evolution of order within the international system towards the end of The Anarchical Society (Bull 1995: 248–85); acknowledging that non-state actors have the ability to play important roles within international society is thus entirely in line with Bull’s own conceptualizations. Within the realm of global health governance, there is clear evidence that non-state actors play a significant role in helping to set the agenda and guide the responses actuated by the international community to health concerns. NGOs like Médecins Sans Frontières (Doctors Without Borders) and Samaritan’s Purse provide a great deal of on-the-ground medical care and were among the first to highlight the international community’s tardy response to the Ebola outbreak in West Africa. Philanthropic organizations like the BMGF and the Clinton Foundation have not only provided funding for various global health initiatives, but also negotiated arrangements between pharmaceutical companies and national governments to provide access to needed drugs like antiretrovirals (Youde 2011a; Youde 2013). While their involvement may generate controversy over their tactics and strategies (Harman 2016; Kaufman 2011), their prominence within global health governance is undeniable.

Lack of Engagement with Economic Issues English School theory devotes relatively little attention to issues of political economy, development, and foreign aid—all of which are elements of global 26

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health governance. This is a striking oversight, given how central economic issues and considerations are to action within international society in the modern era. By failing to engage with international political economy, the English School misses out on key opportunities to marry its theoretical insights with questions of how international society developed and the evolution of globalization (Buzan 2005: 115). When Vincent argues for the need to overhaul the international economic order so as to realize the basic subsistence rights of people, he does little to follow this up or provide insights into how an English School perspective would consider how a remade international economic order would look (Gonzalez-Pelaez 2005: 139–41). Bull even allows that a strong economy may intersect with other dimensions as a way of understanding state power within international relations, but he does not engage with this line of inquiry to any substantial degree (Bull 1995: 108–9). There is no a priori reason that the English School could not or should not engage with international political economy; rather, the lack of attention may be more of a historical accident. Buzan suggests that the early English School theorists ignored international political economy because they had little training in economics, and were largely rooted in a political theory tradition that was ill-equipped to answer economic questions (Buzan 2005: 117). Given the vital importance of economic issues to international relations, it is hard to understand exactly why the English School’s lack of engagement with international economics has continued for so long. There is almost no discussion of international political economy issues like trade policy, foreign aid, or access to foreign markets, even though these issues contribute directly to larger questions of equality and remediation of disparities within the international system. As such, the English School misses out on a large swath of understanding how and why states interact with each other. If the English School focuses its analytical gaze on those primary institutions— fundamental, durable practices that have evolved over time and help constitute legitimate relations—that are constitutive of international society (Little 2007), then it is hard to think of a social practice more constitutive of international society than economics. Watson decries this lack of engagement, writing, ‘Above all, it seems to me that IR theoretical analysis of the role of economic factors is still inadequate’ and fails to recognize ‘the major role played by economic and cultural exchanges in knitting the world together’ (Watson 2001: 469). Barry Buzan has been one of the most prominent English School voices calling attention to the theory’s poor track record with economic issues. In his 2014 book, he decried, ‘The development of thinking about economics within the English School is so poor that there is no consensus, and hardly any discussion, about how to characterise primary institutions in this sector’ (Buzan 2014: 136). Economics’ absence, he suggests in an earlier writing, may 27

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result from the English School’s privileging of the state. A focus on the state leads to an emphasis on the ‘high politics’ of statecraft, diplomacy, and security—issues that have traditionally not given much attention to economic issues (Buzan 2004: 20). If the English School were to add international economic issues to its analyses, though, Buzan suggests this would allow it to develop a more nuanced, fuller appreciation of globalization while also becoming better able to consider how regional linkages play a role in international politics. Furthermore, a lack of engagement with economic issues seriously weakens important consideration of solidarism and reinforces some of the more pessimistic ideas of pluralism (Buzan 2004b: 119). In the 1980s, nascent efforts to include economic considerations in the English School began to appear. R. J. Vincent’s work was central to these efforts. He criticizes Bull for essentially omitting any discussion of economic issues in his work and seeks to make economics more central to international society in his own work (Vincent 1988). To counter these trends, he places economics at the core of international relations through his development of the idea of a basic right to subsistence as an essential element of a global human rights programme. He acknowledges that such an approach would require a wholesale reorientation of the international economic order and how resources are used throughout the worldwide economy, but sees the failure to provide a basic right to subsistence as an indictment of international society as a whole (Vincent 1986: 145). Mayall takes a similar approach, seeing economic relations as a bridge that can unite the Global North and Global South despite their many other differences (Mayall 1982). Despite these initial efforts, economics has remained largely peripheral to the English School. Mayall’s later work considered economic nationalism, but largely couched it in terms of national security (Mayall 1990; 2000b). While Vincent raised the idea of economic reordering to improve international society, he did little to actually develop this notion. He, and those who followed in his similar vein, tended to emphasize protecting citizens from violence by the state instead rather than critically analysing basic rights to subsistence (Gonzalez-Pelaez 2005). Economic relations also possess the potential for exploitation and the reification of unequal power dynamics within international society. They can be a tool for bringing states together and fostering greater integration, but they can also provide an avenue for promoting exclusion and the delegitimation of other states. In his introductory essay to the special issue on the role of the English School in Review of International Studies, Watson posits that developed states provide aid to poorer countries as a tool for maintaining a healthy global economy and transmitting their standards of civilization. Developing states accept these conditions because they need the aid, but he raises the prospect that the emergence of states like China and India as increasingly important 28

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political actors could challenge the West’s ability to use foreign aid to achieve acquiescence to its values (Watson 2001: 469–70). Regardless of the reasoning, the cursory (at best) engagement between the English School and international economics impoverishes theoretical innovation. It prevents the English School from considering one of the most important interactions that happens within the international community. War and diplomacy are surely vital elements of international interactions, but they are not the only ones. Just as a theory of international relations that could not speak to war or diplomacy would find its theoretical leverage lacking, so too does a theory that cannot adequately grapple with how international actors engage each other on economic terms. One of the clearest examples of how global health governance has grown in prominence since the early 1990s (and will be discussed in much greater detail in Chapter 5) is how much more funding is specifically earmarked for DAH. In constant 2016 US dollars, DAH was more than five times higher in 2016 than it was in 1990. This radically outpaces general economic growth during this period, and it is vastly larger than the increases in foreign aid writ large during this same time. An increasing percentage of foreign aid in general is focused on health issues, and this growth, while slowing since 2010, has generally proven resilient even in the face of economic downturns and moves towards austerity. What’s more, an ever-expanding array of actors are getting involved in funding global health. While states gave the overwhelming majority of DAH in 1990, the field has diversified in many ways, with international organizations, public–private partnerships, NGOs, and private actors contributing significant amounts of funding. While this funding provides evidence of the growth of global health governance over the past twentyfive years and allows institutions to carry out some of their responsibilities, it does not mean that global health governance receives sufficient levels of funding to address all of the issues under its purview or that the monies that it does receive are spent in ways that will benefit the most people. It is precisely these sorts of disjunctures that deserve theoretically grounded analysis and highlight the need for English School theorizing to broaden its analytical gaze to better incorporate issues of political economy and efforts to address international inequality.

Conclusion Global health governance has grown at an astounding rate over the past generation and has become an important secondary institution within international society. The growth in funding for global health governance far outpaces general economic growth or changes in official development 29

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assistance, and it comprises a growing portion of the aid funds that donors provide to recipient states. An ever-expanding array of institutions of a variety of types of membership has emerged over the past twenty-five years. More and more actors—both state and non-state—have contributed to the growth and resilience of global health governance. Leading international organizations have incorporated global health into their mandates. Even when it has failed to live up to its expectations, the notion of global health governance architecture and the need to improve it has taken root. There exists an institution within international society—united by common beliefs and expectations around a particular issue—focused on global health governance. To understand how and why this has happened and what the future of global health governance might look like, the English School of international relations provides the best theoretical framework. English School theory is uniquely well positioned to explain the growth and maintenance of global health governance. It provides us with an understanding of the emergence of a normative orientation that unites a group to ameliorate some of the inequities and inequalities that exist within the international system. There is a group of actors with common interests and values that see themselves as bound by a set of common rules in their dealings with each other when it comes to establishing and maintaining the global health governance system. In other words, global health governance is emerging as a secondary institution related to a primary institution of moral obligation and responsibility within international society. It is undeniable that the international community has taken notice of the importance of global health and given it far more prominent status on the international agenda. It has become part of the underlying animating reasoning that motivates international cooperation. This shift manifests itself through significant increases in funding from members of international society, the expansion of actors focused on global health issues, and the prominence global health has achieved on the international political agenda. Using English School theory to understand and explain global health governance provides three key benefits. First, it explicitly integrates international relations theory into the global health politics literature. Despite its increased attention within international relations, the global health politics literature has largely avoided intensive engagement with international relations theory. This impoverishes both global health politics by making it appear auxiliary to the core of international relations, and international relations by failing to integrate global health politics’ insights into its understanding of international cooperation. Second, it provides a framework for analysing cooperation within the international realm. Much of the literature on foreign aid, for example, divides into a debate as to whether states provide funding for humanitarian or strategic purposes (see, for example, Bierce and Tirone 2010; 30

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Easterly 2006; Radelet 2003; Sachs 2005; Schraeder et al. 1998). Such a dichotomization lacks the nuance necessary for understanding the allocation decisions that donors make. It also fails to consider how an international ethos can shape and colour the sorts of deliberations that donors undertake. Third, it allows for an appreciation of how ideas get transmitted through international society, which in turn allows for a careful examination of how ideas can actually have an effect on behaviour that trumps what may seemingly be in an actor’s rational self-interest. At the same time, an English School framework for understanding global health governance forces us to push the English School to adapt to the changing nature of international politics in two key ways. First, it requires that we understand that non-state actors can and do play a role within international society. Most English School theorizing either ignores the role of non-state actors or relegates them to world society and its overly optimistic vision of shared universal norms. Neither is an accurate reflection of the current scene. Arguing that non-state actors play an important role in the creation and maintenance of the norms embraced by international society does not mean that they are entirely replacing states; nor does it mean that we have a reached a universal consensus on values and norms. International society is not a zero-sum game. Non-state actors augment what state actors do. In the same way that membership in international society may vary as states rise or fall, so too does its membership vary as different types of actors come to some measure of prominence—which, of course, does not ordain that they will always be prominent or will be prominent on all issues. Second, the English School has, by its own admission, largely avoided engagement with international political economy and issues of economics and equality writ large. This oversight is puzzling, given the centrality of economic concerns in motivating a wide range of international actions. By incorporating an appreciation for the role of economic factors in international interactions, the English School can extend its explanatory power and engage with a wider range of concerns. Crucial to this argument, though, is an understanding of the role and function of different types of institutions within the English School. Not all institutions have the same purpose. Chapter 2 will examine the role of institutions by focusing on the differences between primary and secondary institutions within English School theorizing. It will also discuss why the English School’s lack of attention to secondary institutions should be remedied. Secondary institutions like global health governance play an important role within international society in their own right, and Chapter 2 will explain how and why.

31

2 Primary Institutions, Secondary Institutions, and Moral Obligation

Institutions make international society possible, but different types of institutions possess their own unique purposes and roles. The English School literature distinguishes between two types of institutions: primary and secondary. Despite the centrality of institutions to the theorizing about international society, a fair degree of ambiguity permeates the collective understanding about the various types of institutions that matter to the English School. There is no common agreement on what constitutes a primary institution in international society, and primary institutions themselves often get inconsistently subdivided and arrayed along a hierarchy. Even more curiously, secondary institutions receive little independent attention. The English School seems to assume that they are simply the concrete manifestations of primary institutions and thus are too ahistorical and divorced from international society’s larger constitutive processes to merit significant attention. Instead, they are relegated to the realm of regime theory. This chapter delves into the understandings of primary and secondary institutions. In so doing, it provides the foundation for asserting that there exists a primary institution of moral responsibility and obligation, that global health governance is a secondary institution connected to that primary institution, and that secondary institutions are worthy of study by English School scholars. We cannot understand the contours of international society without appreciating secondary institutions. Far from being peripheral, secondary institutions are vital in and of themselves. To explore how institutions figure into the English School, this chapter begins by focusing on the distinctions between primary and secondary institutions. It then develops the case for the emergence of a primary institution of moral responsibility and obligation. The third section highlights the relative neglect of secondary institutions and implores the English School to seriously engage with them in order to make international society explicable. This

Primary Institutions, Secondary Institutions, and Moral Obligation

discussion sets the stage for describing the global health governance system and how it fits within the larger context of international society.

Primary and Secondary Institutions Institutions figure prominently in English School theory. According to Bull, institutions are ‘an expression of the element of collaboration among states in discharging their functions—and at the same time a means of sustaining this collaboration’ (Bull 1995: 71). More than just being formal organizations, Bull explicitly argues that institutions are habits and practices that exist for realizing common goals (Bull 1995: 71). As such, they make international society possible and allow its existence to be more than just the sum of its various parts. Institutions offer patterned practices and coherent sets of ideas and beliefs, and they reflect the norms, rules, and etiquette present in international society. They provide the context in which international politics plays out, foster relationships between states, and evince a degree of resilience in the face of challenges (Holsti 2004: 18–22). It is through institutions that we begin to understand the contents of international society. Underscoring this point, Suganami even described scholars working in the English School tradition as British institutionalists (Suganami 1983). Institutions provide order within international society, and the English School pays particular attention to ‘identifying, and investigating the workings of, the institutions of international society’ (Suganami 2003: 253). This understanding rejects Keohane’s definition of institutions, which emphasizes ‘particular human-constructed arrangements’ (Keohane 1988: 383), or identifying them as solely with intergovernmental organizations and legal frameworks (Buzan 2004b: 120). Instead, the English School’s definition of institutions focuses on ‘historically constructed normative structures’ that give rise to cooperation—including cooperation via specific organizations (Alderson and Hurrell 2000: 27). They are ‘part of the efficient causation of international order, and they are among the necessary and sufficient conditions of its occurrence’ (Bull 1995: 71). Institutions can also be a tool for encouraging states to comply with the norms, rules, and behavioural expectations of international society. Institutions help to keep states in check and provide an external standard against which behaviours can be assessed. States of all sorts may still violate the norms and standards set forth within the institutions of international society, and those failures may generate a great deal of attention, but the vast majority of states comply with the expectations generated by and reflected in international society’s institutional arrangements (Holsti 2004: 322). 33

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Primary Institutions Buzan distinguishes between two types of institutions—primary and secondary— within international society. He identifies primary institutions as ‘durable and recognized patterns of shared practices rooted in values commonly held by members of interstate societies, and embodying a mix of norms, rules, and principles’ (Buzan 2004a: 181). Reus-Smit uses a similar definition (though a slightly different nomenclature, calling them fundamental rather than primary institutions): ‘those elementary rules of practice that states formulate to solve the coordination and collaboration problems associated with coexistence under anarchy’ (Reus-Smit 1997: 557). They are basic underlying practices that have evolved over time rather than being consciously created by any particular actor, and they are constitutive of actors and their patterns of legitimate interactions with one another (Buzan 2004a: 167). Furthermore, they have demonstrated their vitality to the system through their longevity. Holsti notes that international society’s foundational primary institutions—among which he includes the state, territoriality, sovereignty, international law, diplomacy, trade, colonialism, and war—emerged in the late seventeenth and early eighteenth centuries, but have (with the exception of colonialism) continued to evolve as international society has evolved and changed (Holsti 2004: 300). In The Anarchical Society, Bull identifies five primary institutions of international society—diplomacy, international law, balance of power, war, and great power management. These five are so vital, he argues, because states have relied and continue to reply upon these institutions to create and maintain order within international society. They are ‘an expression of collaboration among states in discharging their political functions—and at the same time a means of sustaining this collaboration’ (Bull 1995: 71). As will be discussed below, Bull’s list of primary institutions is by no means definitive; indeed, Bull offers different lists of primary institutions in international society throughout his body of work. Even with those variations, though, Bull consistently equates institutions with creating the underlying conditions that give rise to the basic rules of coexistence. An example may help put primary institutions into context. Diplomacy is commonly identified as one of the key primary institutions of international society. Watson’s description of it and how it functions in international relations helps to elucidate why it is so foundational to international society. He states, ‘States are committed to diplomacy by the nature of the world in which they exist’ (Watson 1982: 14). This corresponds with the idea that primary institutions are constitutive of actors and their patterns of engagement with each other. Furthermore, diplomacy has evolved over time and will continue to do so in the future. Watson notes that diplomatic practices began 34

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as sporadic communication between far distant states brought together on the basis of commercial relationships, but that they have gradually expanded to include a wider range of states and a broader array of issues. Over time, these practices have developed their own shared cultural heritage and common values that allow the institution to operate (Watson 1982: 15–16). Most diplomatic interactions today take place within an institutionalized structure that exists independently of any specific issue and conducts business according to well-understood norms, rules, and conventions (Bull 1995: 159–60). These systems were not consciously created; no one sat down to purposely design the diplomatic systems and practices that operate today. They have developed over time to give some degree of order to the interactions that happen between and among sovereign governments. The evolved conventions and practices both inform members of international society how they should act and become a constitutive part of how members see themselves and their own identity within that same international society.

Secondary Institutions Secondary institutions receive far less attention from the English School—to the point that they are frequently dismissed in relatively disparaging terms. Typically, secondary institutions are defined as no more than formal organizations. The United Nations, the International Court of Justice (ICJ), the World Trade Organization (WTO), and the North Atlantic Treaty Organization (NATO) would fall under this category. They are consciously designed organizational manifestations brought about to address specific issues (Schouenborg 2011: 28). As a result, Buzan largely dismisses them. At one point, he goes so far as to declare that secondary institutions do not even have a place within the English School and should instead be outsources to the realm of regime theory because ‘the English School’s institutions reflect something “more fundamental”’ (Buzan 2004a: 167). Clark takes a similarly dim view of secondary institutions, writing, ‘An institution of international society may, but need not, take on an institutional form: whether or not it adopts secondary institutions has no bearing on [its] standing as a primary institution’ (Clark 2009: 219). Reus-Smit uses the term ‘issue-specific regimes’ to describe what Buzan calls secondary institutions, describing them as ‘enact[ing] basic institutional practice in particular realms of interstate relations’ (Reus-Smit 1997: 558). Essentially, these definitions reduce secondary institutions to organized bureaucracies whose singular purpose is to put the concerns of primary institutions into practice. In this conceptualization, the English School focuses on primary institutions because it is more historically oriented, and regime theory addresses 35

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secondary institutions because it is more focused on contemporary events and concrete organizations. What value, then, do secondary institutions hold within international society? Are they truly the poor, neglected cousins of English School analysis, relegated to being undeserving of analysis? While secondary institutions have received far less attention than primary institutions, they hold special and unique roles within international society which makes them worthy of investigation in their own right. Regime theory may offer some beneficial insights that resonate with the English School, but the English School itself has unique perspectives that can offer their own take on the growth, emergence, and effects of secondary institutions. The ‘little explicit [English School] research . . . dedicated to teasing out concrete relationships between the “grammar of the game”—the underlying constitution of international society—and the actual physical international organizations present in world politics’ is a situation ripe for rectifying (Schouenborg 2014: 79). The proclivity within English School analysis to dismiss secondary institutions is theoretically unsatisfying for three reasons. First, identifying what constitutes a primary institution is a potentially maddening exercise. Not only is there no consensus among theorists which institutions are of such import that they are, as Buzan describes them, constitutive of actors, but there is not even agreement within the work of individual theorists. Wilson demonstrates the problem of shifting definitions by calling attention to the works of Martin Wight. He notes that Wight identifies between four and six primary institutions in his own various writings. He further demonstrates that Bull’s interpretation of Wight’s primary institutions leads to either three or four candidates, and Bull himself identifies seven different primary institutions (including international organizations) in three different texts (Wilson 2012: 568–71). Wilson is not the only one to notice these discrepancies. Buzan looks at the work of Wight, Bull, Mayall, Holsti, James, and Jackson and comes up with twenty different candidates for international society’s primary institutions (Buzan 2004a: 174). If primary institutions are to be held up as hierarchically more important than secondary institutions because they are so foundational to state identities, then it would be reasonable to expect a greater sense of analytical and intellectual coherence. Second, the efforts to better identify primary institutions raise problems that end up calling the distinction between primary and secondary institutions into question. Looking at the list of twenty candidates for international society’s primary institutions, Buzan creates two different categories of primary institutions: master primary institutions and derivative primary institutions. The former, he argues, can stand alone and generate the latter, creating a hierarchy among primary institutions. The master primary institutions include sovereignty, diplomacy, balance of power, and nationalism, while derivative 36

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primary institutions include non-intervention, multilateralism, neutrality, and democracy (Buzan 2004a: 184). Interestingly enough, Buzan’s hierarchy actually expands the number of primary institutions. He goes from a list of twenty to create a nested hierarchy of eight master primary institutions and twentyfour derivative primary institutions. There is a value in specifying different types of institutions, but these efforts at specification bring little clarity. Third, there is no reason to set the English School and regime theory in juxtaposition against each other. Both regime theory and the English School derive from the Grotian tradition of international thought and share many similarities (Evans and Wilson 1992). There is no intellectual advantage to supposing that regime theory is only focused on the present and formal organizations. Most definitions of international regimes explicitly go beyond a focus on specific organizations, paying more attention to the ‘principles, norms, rules, and decision-making procedures’ that govern state behaviour in particular issue-areas (Krasner 1983: 2). It may be true that the power-based theories of international regimes that are synonymous with neorealism pay relatively little attention to history and give little autonomous role to international organizations, but that is a function of neorealism and not of regime theory itself. Identifying regime theory entirely with power-based explanations misses out on the more robust, nuanced, and vital approaches to regime theory. Knowledge-based theories of international regimes, in contrast to power-based approaches, explicitly recognize that identities and interests are not exogenously given and that institutions shape and are shaped by normative and causal beliefs among actors (Hasenclever et al. 1997: 136–7). Such an approach necessarily involves an appreciation of the role of history and evolution. Furthermore, no less an English School theorist than Barry Buzan himself has argued for the value of regime theory in the English School. He writes: Regime theory and international society are part of the same tradition, but due to the peculiarities of academic discourse, they have become largely detached from each other. Regime theory has made considerable progress in its own right and could now benefit from being reconnected to the older tradition of international society. (Buzan 1993: 328)

As Buzan himself makes clear, there is substantial potential value in combining the insights of the English School and regime theory. As such, it makes little sense to relegate secondary institutions solely to the realm of regime theory and pay almost no attention to these institutions. After all, these are the most prominent and direct manifestations of the various primary institutions that exist, and it behoves the English School to pay attention to how primary institutions get translated into action. Exiling a major portion of international society to another theoretical tradition weakens the overall explanatory power 37

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of the English School and diminishes our understanding of how international society operates. The problem is thus not the distinction between primary and secondary institutions itself; rather, it is the underspecification of secondary institutions within English School theory. Such a dismissive attitude leaves us with a sense that secondary institutions are simply derivative of primary institutions and without any need to analyse them as autonomous actors in and of themselves (Spandler 2015: 602). This impoverishes the English School because it leaves the theory without a good mechanism for understanding institutional change or seeing how primary institutions manifest themselves into secondary institutions. Along these same lines, it makes little sense to assume that secondary institutions lack any sort of constitutive dimensions within international society on their own. Spandler argues that secondary institutions possess their own constitutive characteristics that shape actors and their legitimate interactions with others. He gives a more expansive understanding of secondary institutions, defining them as: Sets of discursively formulated expectations, but they are more specific [than primary institutions] in that they refer to temporally and spatially discrete sections of international reality and apply to a clearly defined set of actors. (Spandler 2015: 613)

In this way, secondary institutions act constitutively. Primary institutions are constitutive because they define who the relevant actors are and the relationships between them. Secondary institutions are constitutive because they provide differentiated roles to actors, empower engagement among the recognized actors, and define identities, interests, and capabilities in more detail than primary institutions can (Spandler 2015: 610–13). It may be true, as Clark argues, that the particular secondary institutions that emerge around any given primary institution simply reflect the moment in time and peculiar historical circumstances (Clark 2009: 219). Even if that is the case, though, then those specific secondary institutions that do emerge tell us a huge amount about the contexts in which a primary institution exists. Furthermore, those secondary institutions give form and substance to the primary institution. The secondary institutions or their particular structures may change over time, but so do primary institutions and their understandings of their place within international society. To deny the potential constitutive power of secondary institutions is to ignore how primary institutions take root within international society. To take one example of the constitutive power of secondary institutions, think of NATO. With the end of the Cold War and the demise of the Soviet Union and its collective security organization, the Warsaw Pact, there was ostensibly no reason for NATO to exist. It was a collective security organization 38

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designed to protect states against an enemy that no longer existed. Such an interpretation, though, misunderstands what NATO came to represent and the value that it had both for its members and for those Central and Eastern European states that sought membership in the organization in the 1990s and 2000s. NATO membership was not and is not just about collective security; it is about identifying with and evincing a certain set of norms, values, and ideas. NATO membership signifies a belief in liberal democracy, human rights, and market economics. Potential member-states sought such recognition by the West as a symbol that they had emerged from their previous political and economic structures and were ready and interested in participating in the international community. The possibility of NATO membership thus gave states a goal for which they could strive and an identity which they wished to embody (Schimmelfennig 1998). In this way, NATO membership becomes constitutive of its members’ identities. It is indeed true that a secondary institution like NATO is connected to primary institutions like diplomacy, great power management, and alliances, but it is specifically membership within an organization like NATO that firmly demonstrates how an institution can be constitutive of a state’s identity. This demonstrates that organizations are not merely administrative bodies, but hold greater meaning and the potential for change that is deserving of theoretical attention. The reluctance by much of the English School literature to engage with secondary institutions or understand them as anything other than specific organizations limits its ability to engage with the ways in which international society constitutes itself in the contemporary era. International society may not be dependent upon secondary institutions like the United Nations, but the United Nations and other such secondary institutions are dependent upon international society (Parrat 2014: 11). Primary institutions may, as Adler argues, construct actors and the rules of the game in international society in a broad sense (Adler 2005: 175), but secondary institutions are even more direct and apparent. Rather than assuming that any study of secondary institutions must ‘take both actors and their preferences as given’ (Buzan 2004b: 120), the English School has the tools to explore how secondary institutions translate the normative commitments of primary institutions into practice— both in terms of specific, formal organizations and more diffuse practices, habits, and behavioural expectations. Secondary institutions are where that intersection occurs, and it is worthwhile to explore these ties.

Moral Obligation and Responsibility as a Primary Institution Primary institutions exist to give some semblance of order to international society. They offer a relatively stable set of norms, rules, and principles that 39

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help to determine the nature and shape of international society (Makinda 2002: 366). This does not mean that the primary institutions of international society are static; Alderson and Hurrell note that even Hedley Bull himself recognized that robust institutions could and would change over time (Alderson and Hurrell 2000: 37). To this end, new primary institutions will emerge over time—and one of these is the primary institution of moral obligation and responsibility. By this, I mean that international society has developed a set of norms, rules, principles, and expectations that centre around the vital importance of states to provide assistance to peoples outside their own borders so as to reduce suffering and facilitate the creation of an environment in which individuals can potentially prosper. It includes both acts of omission and commission, meaning that there is both an obligation to avoid intentionally causing injury to others and some degree of positive obligation to improve another’s station in life (Linklater 2011: 51–61). In many ways, the primary institution of moral obligation and responsibility is akin to the promotion of a common good. It does not mean that international society has agreed to specific standards or quantitative measures of what constitutes the common good. It also does not mean that actors will abjure their own self-interest in the pursuit of assisting others. Instead, it recognizes the solidarist interest in promoting the health, well-being, and security of all persons while still acknowledging the pluralist concern for allowing actors to retain policy autonomy. In this way, the primary institution of moral obligation and responsibility blends pluralism and solidarism to reflect the competing interests and concerns that exist within international society. Its precepts may come into conflict with other primary institutions, but tensions among international society’s primary institutions should not be unexpected and could actually provide for a measure of dynamism and opportunities for change (Buzan 2004a: 250). The idea of moral obligation and responsibility as a primary institution within international society leads us to reconsider the possible tensions between order and justice. Nardin highlights two particularly tricky issues when thinking about the role of justice in international society. First, he identifies how underspecified justice is. Because Bull and his contemporaries primarily emphasized order as the key element before justice could be achieved, ‘justice is contentious and therefore cannot be defined; the best we can do is describe alternative perspectives on it’ (Nardin 2005: 248). Second, the growth in attention to globalization within international relations has altered our conceptions. In particular, he ties globalization to the emergence of identifying justice with world society and its cosmopolitan ideals as opposed to international society (Nardin 2005: 248–9). Equating justice solely with world society is problematic, though, as it reduces the likelihood of achieving positive outcomes within international society and is overly deferential to a narrow 40

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interpretation of pluralism. Nardin resolves this ambiguity by arguing that, regardless of the nature of the community in question (international or world), justice is fundamentally about ‘which moral rights and duties may be coercively enforced by being incorporated into a relevant body of law’ (Nardin 2005: 249). While this approach may hold some intuitive appeal, its explicit connection between justice and law relies on an overly formalistic standard. That is not to argue that international law is irrelevant or non-existent; rather, the concern is with the potential mismatch between obligation and legal requirement. Coercion is not a useful strategy when addressing the myriad of potential violations of moral obligations and responsibilities, and transforming morality into international law may require the fruition of world society that is simply not in existence at the current time and unlikely to become so in the near future. Wheeler offers a different framework for thinking about the potential tensions between order and justice. International society ‘does not provide for perfect order, but it does deliver a platform upon which what little justice does exist in world politics can be erected’ (Wheeler 1992: 487). Drawing heavily on Vincent’s work, Wheeler acknowledges that states do not always respect the claims to rights by others or their various moral obligations. Rather being a cause for despair, though, he invokes Vincent to argue that such violations should actually provide a ‘clarion call to action’ (Wheeler 1992: 479). He finds a balance between Bull’s latter works, where he moves closer to solidarism while remaining true to his pluralist roots, and Vincent’s arguments in favour of human rights that privilege a solidarist perspective tempered by ‘powerful pluralist instincts’ (Wheeler 1992: 481). In so doing, Wheeler establishes a balance between order and justice, and how both concepts intersect with morality, by absolving the international community of the need to be perfect. There can be a collective agreement about the value and importance of seeking to realize various moral obligations and responsibilities within international society, but that agreement is tempered by a recognition that even seemingly universal principles are open to some degree of interpretation by implementing states (Wheeler 1992: 481). A primary institution of moral obligation and responsibility picks up on some of the themes Bull emphasized during the latter part of his career. Makinda explores how Bull came to focus on issues of human rights and inequalities between the Global North and the Global South (Makinda 2002: 367–9). Bull argued that the Global North had a moral imperative to assist the Global South and believed in the need for a greater transfer of power and wealth as constitutive of creating a more equitable and stable international order. ‘We must take the Third World seriously,’ he wrote, ‘primarily because of the vital interest we have in constructing an international order in which we ourselves will have a prospect of living in peace and security into the next 41

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century and beyond’ (Bull 1983: 128–9). The following year, he made his argument even more forcefully, stating that there ‘may even be said to be a consensus among the advanced countries that they have a responsibility to maintain certain minimum standards of human welfare throughout the world as a whole’ (Bull 1984a: 12–13). What is particularly notable about Bull’s argument, though, is that it is primarily normative and prescriptive rather than descriptive. Bull was bemoaning the lack of recognition of this sense of moral obligation and responsibility that wealthier states should have for poorer states. He was calling attention to the nascent development of these attitudes within international society, not describing the norms, rules, and principles then at work within international society. In the time since Bull’s death, we can see how his ideas and beliefs have come to take root within international society and are becoming increasingly constitutive of the members of international society. Bull was not the only English School theorist calling attention to emergent beliefs within international society about overcoming the discrepancies between rich and poor states. Writing shortly after Bull’s death, Vincent focuses his attention on the role of human rights and how they should fit into international relations, especially around relations between the Global North and Global South. Vincent advocates for recognizing the right to subsistence—which includes food provision, access to potable water, and maintenance of public health systems—as the most vital element of human rights and, importantly, a shared consensus to which states can agree (Vincent 1986: 145). This formulation of basic rights allows for the maintenance of state sovereignty, but it adds a solidaristic element to international society (Gonzalez-Pelaez 2005: 20). This is not about overthrowing the existing system, but rather about recognizing the collective interest in making the current system work better for more people. The specifics of any given programme and the tools used to realize the right to subsistence will vary, but the underlying ideas themselves do not. The debate is over the implementation of the right, not the right itself (Gonzalez-Pelaez and Buzan 2003: 327–8). As with Bull’s emphasis on justice, Vincent is describing the world he would like to see rather than the world that exists at the time. That said, he sees glimmers of possibility and wants to offer practical policy advice. What sorts of practices, rules, and norms would fall under the umbrella of a primary institution of moral obligation and responsibility? We could look to the renewed interest in Vincent’s basic rights initiative (Gonzalez-Pelaez 2003), discussions of a right to subsistence (Gonzalez-Pelaez 2005), efforts to connect environmentalism and international society (Falkner 2012; Palmujoki 2013), and even the arguments about humanitarian intervention or the existence of international legal conventions against harm (Linklater 2001; Wheeler 2000). These sorts of practices are embedding themselves within international society. 42

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Hurrell highlights a number of issues that are increasingly important to international society, such as human rights, democracy, and global environmentalism (Hurrell 2007). His arguments for the increased importance of environmentalism within international society are particularly telling and get at the reasoning for the emergence of a primary institution of moral obligation and responsibility. He argues, ‘The increased seriousness of many environmental problems provides one of the most intuitively plausible reasons for believing that the traditional forms of international society are inadequate and that the nation-state and the system of states may be heading toward a crisis’ (Hurrell 2007: 216). This is because the state is simultaneously too big and too small to address the challenges the international community faces. It is too big because it does not allow for the sort of decentralization and grassroots level approaches that actively engage affected communities, but it is too small because the transnational nature of issues like the environment, health, and the flow of refugees simply cannot be addressed by a single state acting on its own. Coordinated action beyond the level of the state is absolutely necessary. As such, these sorts of issues can help to engender a sense of interdependence that has the potential to introduce new non-territorially based political identities, call into question previous assumptions about strictly pluralist approaches to international society, and encourage the development of new forms of global governance that embrace both state and non-state actors (Hurrell 2007: 218). Even though there are failures on specific issues within each of these areas, the underlying norms themselves are being woven into international society’s normative framework (Falkner 2012: 503). Hurrell writes, ‘The importance of, say, the global environmental movement does not lie in terms of the direct degree of influence it has achieved, but rather in terms of deeper shifts in environmental consciousness, and in the creation of new political identities within new forms of transnational political space’ (Hurrell 2007: 102). Taking global health governance as an example, while the specific institutional responses to the Ebola outbreak fell short in many ways, the underlying ethos about the value of mobilizing global resources to address health issues and the identities and behaviours that the primary institution of moral obligation and responsibility implies remains. Failure to live up to the standards implied by the existence of a primary institution is not proof of the absence of that primary institution. Tensions and inconsistencies will exist within the broad scope of any primary institution, but their existence does not render the entire primary institution itself moot. There may be a temptation to assume that any of the particular institutions mentioned above could be primary institutions in and of themselves. Palmujoki suggests that mitigating climate change is a newly developing primary institution (Palmujoki 2013: 196–7), and Yaqing hints that China’s full 43

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membership in international society may be delayed because it does not accept the primary institutions of human rights, democracy, and environmental friendliness (Yaqing 2010: 130). Even Buzan himself, taking a cue from Jackson, suggests that environmentalism may fall within the realm of primary institutions, which in turn generates derivative institutions like species survival and climate stability (Buzan 2004a: 186–7; Jackson 2003: 175–8). Talking about any particular issue as a primary institution can be attractive. Primary institutions receive a great deal of attention from states and are therefore prioritized. In addition, if there exists a hierarchical relationship between primary and secondary institutions, as Buzan asserts, then advocates would want to frame their issue as a primary institution in order to generate international attention. Though I have some degree of sympathy for these arguments about elevating various international practices to the realm of primary institutions on their own, it is more appropriate to consider practices like environmental stewardship, human rights, humanitarian intervention, the provision of basic rights, and global health governance as parts of an overarching primary institution of moral obligation and responsibility for three reasons. First, these issues share broad themes in terms of the policy and practice responses that we see within international society. The specific organizations and rules will obviously differ from issue to issue, but these issues possess a common need for comprehensive multilateral responses in order to satisfy their demands. Indeed, these issue areas frequently learn from one another. Second, not all issues can rise to the top of the international agenda. If primary institutions are those issue-areas that both shape conduct within international society and are top of mind for policymakers, then there is a value in restricting that list. Third, the realization of the goals in any of these particular areas requires focusing on both the ideas behind them and the concrete organizational and legal structures required to put them into practice. They require a careful analysis of the relevant secondary institutions. While the dividing line between primary and secondary institutions is blurrier than Buzan and others claim, there is a distinct value in separating them out from each other. Grouping these various practices together in a single broad primary institution thus provides us with greater analytical leverage and a better way to understand how international society manifests primary and secondary institutions. Evidence for the emergence of this primary institution of moral obligation and responsibility comes, in part, from the substantial growth of and attention to international agreements and goals dealing with the relevant issues in recent years. We could look to the emergence of Responsibility to Protect (R2P), an idea passed unanimously at the conclusion of the 2005 World Summit. We could also look to the Millennium Development Goals (MDGs)—a set of eight ambitious international development goals dealing 44

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with issues like eradicating extreme hunger, reducing child mortality, ensuring environmental sustainability, and promoting gender equality. These goals set out both specific targets and a finite timeline for trying to accomplish them, and they were developed after widespread consultation. When the MDGs expired in 2015, the ideas they embodied did not simply disappear. Instead, they developed into something even more ambitious—the Sustainable Development Goals (SDGs). The SDGs include seventeen different goals, designed to be even broader than the MDGs while still providing a sense of guidance for the international community over the next fifteen years. The SDGs include ending poverty, reducing inequality, combatting climate change, making cities and urban areas resilient and sustainable, and providing access to sustainable and modern sources of energy. In all of these—R2P, MDGs, and SDGs—there is an overwhelming ethos of shared responsibility among all states to address the problems that cause ill health, a lack of economic development, and the inability of people to live lives of choices. The above notion of a primary institution of moral obligation and responsibility is in many ways Vincentian in its nature. While Vincent is certainly not the only English School theorist to call attention to the existence of moral obligations and responsibilities within international society, he was among the first to consider these obligations in a comprehensive manner. In particular, Vincent wanted to reconcile the notion of human rights with the idea of universality. He noticed that human rights were becoming an increasingly important element in international relations, but he worried that the definition of what constituted human rights varied throughout the world and took on an inappropriately universalist aura in much of the Global North. His task was to find a way to conceptualize human rights that both allowed for their provision within international society and was not so overtly solidarist in its understanding so as to alienate governments. Vincent argues that the provision of subsistence rights—taking care of the provision of food, potable water, public health, and ‘the education that makes possible the integration of these processes’ (Vincent 1986: 145)—should be prioritized over other human rights and that subsistence rights provide the international community with a basic floor below which states should not fall in their attention to their populations. Furthermore, he emphasizes that this strategy preserves the pluralism within international society because it does not specify exactly how states must realize these rights, while simultaneously promoting a degree of solidarism because it acknowledges a basic set of rights whose realization should be independent of country of residence. He also sought to provide an avenue through which the English School could have meaningful engagement with questions of international political economy. Vincent’s strategy brings the notion of moral responsibility firmly into the realm of international society while also acknowledging the potential issues that can complicate its actualization. 45

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Sadly, Vincent’s premature death meant that he was unable to further elaborate upon his ideas or expand them into other areas. Gonzalez-Pelaez and Buzan have sought to resuscitate Vincent’s ideas and extrapolate from them. They laud Vincent for bridging the pluralist demands of international society with a recognition of our shared humanity (Gonzalez-Pelaez and Buzan 2003: 322). They particularly cite his lowest common denominator approach—find the most basic issue on which members of international society can agree—for providing a plausible foundation for building other, more extensive practical measures that elevate our collective normative commitment (Gonzalez-Pelaez and Buzan 2003: 332). Gonzalez-Pelaez (2005) continues to expand upon Vincent’s legacy in her book, Human Rights and World Trade. In it, she uses Vincent’s basic rights initiative as a jumping off point for discussing how international society by and large recognizes the existence of a right to food, but that the practical necessities required to make this right a reality remain relatively underdeveloped. She makes both a call for changes within international society to better allow it to recognize the right to food and for a greater appreciation of Vincent’s contributions to English School theory more generally. The existence of these sorts of internationally recognized agreements provides evidence of the importance of these ideas within international society and how they shape the actions of actors within that society. Of course, the presence of international agreements in and of itself is not definitive proof of a primary institution, but the broad-based support for these ideas and the international community’s attention to these ideas reinforces the notion of moral obligation and responsibility as a primary institution.

The Importance of Secondary Institutions Given the emergence of this primary institution of moral responsibility within international society, it is important to understand how secondary institutions work in conjunction with the overarching primary institution. The vital role of secondary institutions emerges in two key ways relating to the primary institution of moral obligation and responsibility. First, they give meaning to international society. As Spandler argues, international society is more than the sum of its parts because it is the interactions that occur within international society that provide some sort of intersubjective meaning to the processes associated with international society (Spandler 2015: 605). Those interactions take place within secondary institutions. They are the forums in which states interact with one another, sharing information, ideas, and norms about expected standards of behaviour. In other words, understanding what sorts of actions and behaviours are legitimate within international 46

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society can only come about through an understanding of the actual interactions that occur within regimes and organizations. There may be an idea of what sovereignty means in theory, but it only becomes useful as an analytical tool when we investigate how sovereignty actually plays out in practice through organizations and regimes. This means that secondary institutions are more than just regulatory; they have their own constitutive effects on international society and the actors within it. ‘The constitutive character of specific rules—or secondary institutions—is rooted in the acknowledgement by the actors that their identity as a member of the international community is dependent on their acceptance of the rules,’ Spandler emphasizes (2015: 608). From the above, it is clear that it is valuable and worthwhile to consider secondary institutions as something more than just formal international organizations. The inclusion of regimes within the definition of secondary institutions necessitates such a move. Second, even though secondary institutions have not received a high degree of attention from the English School, recent studies have demonstrated how secondary institutions play a crucial role for manifesting international society and illustrating the conflicts that exist within international society. Parrat uses an English School framework to analyse the United Nations and the relative slowness of the reform processes within that organization. She argues that the languid pace of reform should not be a surprise because ‘the process of UN reform actualizes very fundamental questions about how international interaction should be organized and is, therefore, necessarily slow and constantly contested’ (Parrat 2014: 8). In other words, the reform processes within the United Nations reflect the larger debates within international society about moral obligation and international cooperation—debates which are necessarily going to take a long time and involve a great deal of contestation. Palmujoki discusses the importance of the United Nations Framework Convention on Climate Change and other similar types of agreements and organizations, but he explicitly frames them as evidence of the emergence of climate change governance as an emergent institution within international society (Palmujoki 2013). Falkner shows how the growth of various UN conferences on environmental protection provide evidence that global environmentalism is an emergent institution within international society (Falkner 2012). Linklater touches on the role of secondary institutions in his analysis of the development of cosmopolitan harm conventions throughout time. He points to specific treaties, like the 1948 Convention on the Prevention and Punishment of the Crime of Genocide and the 1973 International Convention on the Suppression and Punishment of the Crime of Apartheid as contemporary manifestations of international society’s long-standing interest in promoting the prevention of harm (Linklater 2001). Collingwood explores questions of legitimacy within international society through her focus on the role of 47

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transnational non-governmental organizations (NGOs). She argues that transnational NGOs are assuming greater roles within global governance, but remain subject to questions about whether they have any legitimate right to exercise such power and influence (Collingwood 2006). While many traditional English School theorists would not include NGOs under the umbrella of secondary institutions, Collingwood convincingly argues that they deserve analytical attention because of their contribution in a wide range of different issue-areas. Murden discusses how secondary institutions like the Arab League, Gulf Cooperation Council, and Arab Maghreb Union are partial expressions of local understandings of primary institutions within Middle Eastern international society (Murden 2009). Schouenborg utilizes a similar regionally oriented approach, focusing on the Nordic Council as a concrete expression of the shared commitment to welfare-state ideology among Scandinavian governments (Schouenborg 2013). Through this research, it becomes clear that there is something special and unique about the role that secondary institutions play in the emergence, growth, and resilience of international society.

Conclusion There is no inherent reason why the English School cannot apply its insights to the study of secondary institutions. The reluctance is rooted less in any a priori reason and more in an overly narrow conception of what secondary institutions do and their role within international society. There is value to distinguishing between primary and secondary institutions, but there is no value in analytically shortchanging secondary institutions or assuming that they have no constitutive effect of their own. Primary institutions provide the overall shape to international society, while secondary institutions give form and function to international society. In the case of this book, we see the emergence of a primary institution of moral obligation and responsibility, which in turn is supported by the secondary institution of global health governance. Secondary institutions have a role to play on their own within international society, and they should not be dismissed as only of importance to regime theory. This is not to denigrate regime theory; indeed, regime theory and the English School possess a number of interesting points of analytical affinity. That said, the English School’s emphasis on understanding historical context and looking at the long term can inform the study of secondary institutions. Furthermore, by taking a more expansive view of secondary institutions as encompassing more than individual intergovernmental organizations, we arrive at a more fruitful understanding of how secondary institutions operate in support of their related primary institutions. 48

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Organizations do not operate in isolation, so studying them in isolation unnecessarily narrows out analytical capacities. Chapters 3 and 4 will go into detail about the evolution and component parts of the secondary institution of global health governance. Global health governance encompasses both a range of formal organizations and normative and behavioural expectations. The formal organizations include intergovernmental bodies, public–private partnerships, NGOs, philanthropic organizations, and private businesses. The normative expectations include an understanding of the importance of addressing cross-border health problems, a willingness to cooperate to address global health emergencies, and support for collaborative health efforts. These all combine to create a set of understandings and expectations that are themselves constitutive of the obligations of members of international society. They make international interaction in the health space possible. Global health governance is by no means perfect, and its systems are in serious need of reform, but there is no doubt that the norms, rules, and behavioural expectations exist around global health and that these contribute towards the efforts to realize the primary institution of moral obligation.

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3 The Evolution of Global Health Governance

Institutions in international society are not static. They evolve and change over time, adapting to new conditions and new situations. English School theorizing specifically emphasizes the evolutionary and adaptive nature of international institutions, as institutions are what allow for the creation and maintenance of a sense of order and justice. In order to understand the emergence, growth, and resilience of an institution in international society, it is important to trace its evolution. This is particularly true with the secondary institution of global health governance, as it combines specific formal organizations, international treaties, and normative practices within its operational melange. While contemporary global health governance did not really come into its own until the 1990s, its origins go back much further. The evolutionary process begins in the mid-nineteenth century with the first efforts among states to craft international standards for the implementation of quarantine procedures. Since that time, global health governance has become increasingly institutionalized, expanded to include a broader range of actors, and broadened its normative orientation away from pure self-interest and towards one that recognizes health as a vital element of human rights and development. It is only through understanding its earlier evolution that we can understand how its current normative commitments and behavioural expectations emerged. This chapter examines how cross-border health cooperation efforts have evolved over time. There is a gradual move from a system that is entirely state-based and organized largely around economic concerns to one that sees the emergence of intergovernmental organizations, the broadening of membership, and a more expansive sense of meliorism. This shows the steady move away from international health governance towards global health governance and the consolidation of a shared normative basis for action when it comes to transnational health concerns.

The Evolution of Global Health Governance

To understand these changes, this chapter focuses on seven key organizations, issues, and campaigns that illustrate the changes to and evolution within global health governance: • • • • • • •

the International Sanitary Conferences (ISC) the League of Nations Health Office (LNHO) the World Health Organization (WHO) the Health for All by 2000 movement the International Health Regulations (IHR) the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) the Bill and Melinda Gates Foundation (BMGF).

With each of these, we see the emergence and consolidation of global health governance in support of the primary institution of moral obligation and responsibility and international society more broadly and how these processes move from self-interested economic rationales to more of an other-regarding rationale. We also see the diversification of actors and the role of economics in actuating these shifts. It is also important that not all of these efforts have been successful. When some of the ideas do not get taken up by international society or are embraced in a more limited sense, it provides evidence of the continued contestation that exists over the exact nature of global health governance. These seven elements of global health governance are particularly important for three reasons. First, they show how globalization has played a significant role in expanding global health governance. There is a trend towards deterritorializing health, broadening the notion of health to encompass a more holistic vision, and exploring the connections between the spread of economic and intellectual ideas and the growth of global health governance (Aginam 2005; Ng and Ruger 2011). Second, they demonstrate the continual expansion of the range of actors involved. Global health governance moves from a system that is entirely state-centric to one that incorporates international organizations, non-governmental bodies, and private actors. Third, they demonstrate how the rationales undergirding global health governance have changed and evolved over time. Economics, security, and human rights have all played a role in legitimating the need for global health governance, and these different ideas have influenced the types of organizations that play a role in global health politics (Youde 2016).

The International Sanitary Conferences The beginnings of what we now consider global health governance come not from a sense of altruism; rather, it was a combination of fear and economic self-interest because of one infectious disease—cholera. Cholera is a bacterial 51

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illness that tends to kill quickly when an outbreak occurs and whose spread frequently mirrors trade routes. Vibrio cholerae, the bacterium that causes the disease, spreads through infected food, unclean water supplies, and bodily waste. Early symptoms of infection include a bloated abdomen, which quickly gives way to watery diarrhoea. The diarrhoea causes severe dehydration and kidney failure, and can result in death in as little as eighteen hours from the time of infection. McNeill offers a vivid and disturbing description of the disease’s progress: Radical dehydration meant that a victim shrank into a wizened caricature of his former self within a few hours, while ruptured capillaries discoloured the skin, turning it black and blue. The effect was to make mortality uniquely visible: patterns of bodily decay were exacerbated and accelerated, as in a time-lapse motion picture, to remind all who saw it of death’s ugly horror and utter inevitability. (McNeill 1998: 266–7)

In the absence of effective treatment, mortality rates can reach 50 to 90 per cent. The speed with which it kills and its highly lethal nature made cholera one of the most feared diseases in the nineteenth century. Even before it reached Europe, reports from British colonial officials in India raised alarm among both governments and the general public. Between 1817 and 1827, British Army officials reported that the disease killed 10,000 of its troops, while an estimated one million Indians also died of cholera during that time period (McNeill 1998: 267–9). During the nineteenth century, Price-Smith estimates that cholera caused 25 million deaths in India (Price-Smith 2009: 49). It was particularly fearsome during this time period because ‘it seemed to thrive in overcrowded and squalid localities’ (Harrison 2012: 139)—a descriptor that applied to many of the world’s cities at the time. Most epidemiological genealogies trace cholera’s origins to India. Specifically, they describe it as initially being endemic to the Bengal region of India, and the first outbreak recorded by Europeans happened in 1817 near what is now Kolkata (Aberth 2011: 102). This connection between cholera and India in the popular imagination gave the disease and its perception a particular gloss, with ‘cholera’s oriental associations conjur[ing] images of darkness and degeneracy’ (Harrison 2012: 139). The historical record indicates that cholera first reached Europe around 1829 and spread throughout the continent by following trade routes. Within three years, it had reached both London (killing 6,000 in the first year) and Paris (causing 7,000 deaths) (Rosenberg 1987). As the disease spread throughout Europe, people linked it to outsiders and disfavoured groups. In Russia, foreigners were blamed, while many in Britain blamed the French and the poor for bringing cholera to its shores. Muslims and Hindus also found themselves singled out for being responsible for the disease’s spread, particularly in conjunction with religious pilgrimages (Aberth 2011: 104–5). 52

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This connection between the movement of people and goods and the spread of cholera gave rise to the widespread use of quarantine by governments. Quarantine has biblical origins, with the book of Leviticus mandating that those with leprosy be exiled away from settlements as long as they have the disease because they are ‘unclean’. The first officially recorded use of government-sanctioned quarantine occurred in 1377. In that year, the Rector of the Republic of Ragusa—a small republic near contemporary Dubrovnik, Croatia—ordered all ships coming from ports known or suspected of having bubonic plague to anchor away from the port for thirty days. If the disease did not break out during this period, the ship could then bring its goods ashore and engage in normal commerce (Frati 2000). Over time, this policy expanded to include land travellers and increased to forty days. Ragusan officials defended the practice of quarantine specifically on commercial grounds, describing it as vital for protecting the ‘quality and safety of the trade network’ (Gensini et al. 2004: 258). Other governments adopted similar policies and expanded the use of quarantine to include additional diseases, including cholera. Even though quarantine proved popular, its efficacy in stopping the spread of disease was ‘largely fortuitous’ and quarantines themselves were ‘generally useless, but they were exasperating, obstructive, oppressive, and often cruel to the point of barbarity’ (Goodman 1971: 34). Governments expanded their use of quarantine to justify locking up anyone who looked ‘suspicious’—an incredibly broad label that political leaders used to take action against any disfavoured groups or perceived enemies (Tesh 1987: 12). Governments may have had few qualms about the social effects of quarantine, but they did raise concerns about its effects on commerce. As international trade relationships developed and deepened in the middle of the nineteenth century, quarantines slowed down shipments, increased costs, and were applied inconsistently and with no coordination among governments. Quarantine’s negative effects on international trade and travel gave rise to the initial calls for international standardization. Howard-Jones describes the problem: What governments found most irksome were the often disastrous impediments to international commerce, and it was this concern that finally prompted the European nations to meet to discuss to what extent these onerous restrictions could be lifted without undue risk to the health of their populations. If, in the old colonial days, it was true that ‘trade follows the flag’, it was equally true that the first faltering steps towards international health cooperation followed trade. (Howard-Jones 1975: 9–11)

Governments began voicing the need for an international conference on cholera control as early as 1834, but it took seventeen years for those pleas to come to fruition. In 1851, twelve European governments came together 53

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in Paris to discuss cholera regulations. Initially, the assembled parties sought to create uniform policies for the use of quarantine procedures and discuss the possibility of creating an international sanitary body to oversee maritime regulations (Goodman 1971: 42–3). The conference delegates did actually produce a convention complete with eleven articles and 137 regulations aimed to address cholera, plague, yellow fever, and other diseases ‘reported to be importable’ (Goodman 1971: 46). This initially appeared to be an encouraging beginning to international health regulation. Unfortunately, only three states—France, Portugal, and Sardinia—ratified the convention, and Portugal and Sardinia withdrew their ratification in short order because they found the regulations overly burdensome to implement (McFadden 1995: 46–7). Given the seemingly shared interest in coordinating quarantine policies and removing impediments to cross-border commerce, it may seem odd that the parties could not arrive at an agreement. The continued disagreements persisted because the states lacked a shared consensus on the appropriate actions to take. Their differences were rooted in geography, commercial interests, and epidemiology. States along the Mediterranean Sea, which were more likely to experience outbreaks in their ports first, argued in favour of quarantine more strenuously. States more heavily dependent upon trade generally expressed more concerns about quarantine policies, since they slowed the exchange of goods (McFadden 1995: 47). The lack of scientific consensus on the aetiology and spread of cholera played an important role in frustrating agreement. Before Robert Koch proved the existence of the Vibrio cholerae bacterium in 1883, and even for some time afterwards, there existed three main theories to explain the disease’s spread. Each theory—miasma, contagion, and supernatural—came with its own perspective on quarantine. The miasma theory posited that weather, climate, and ‘pestilent air’ caused poor environmental conditions that allowed cholera to thrive (Tesh 1987: 25–32). Because of its focus on ambient conditions, supporters of the miasma theory saw little role for quarantine. Instead, they recommended improved sanitation standards. This theory appealed strongly to the trade-dependent states who viewed quarantine as an artificial impediment. British officials, for example, called for the abolition of quarantine and its replacement with ‘sanitary regulations’ (Goodman 1971: 46). Contagion theory argued that cholera spread from person to person, meaning that its supporters saw a vital role for quarantines in separating the sick from the healthy. In practice, though, such policies acted as a license for discrimination. Foreigners and Jews bore the brunt of the effects. They were described as dirty, which encouraged suspicions that they spread cholera. Governments then took action against these groups under the guise of protecting the public’s health (Tesh 1987: 13). 54

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The supernatural theory blamed cholera on God. Illness appeared in a community as divine punishment for sinful behaviour, so churches in affected communities would frequently hold special prayer services in an effort to cleanse the community (Tesh 1987: 17–21). This theory saw little role for quarantine, since it believed that cholera would persist until the community had repented enough to please God. The head of the Austrian delegation even saw cholera as something that benefited society, since it punished ‘the dregs of society’ and encouraged any survivors to lead a more pious life (Howard-Jones 1975: 13–15). With this lack of a shared understanding about the commercial implications of coordinated quarantine policies—to say nothing of any sense of moral obligation or responsibility of states to assist those in need—the earliest efforts to create some measure of international health governance found little formal success. Over the next forty years, delegates gathered five more times—Paris in 1859, Constantinople in 1866, Vienna in 1874, Washington in 1881, and Rome in 1885—but these conferences similarly failed to produce any substantive agreements. Countries continued to introduce their own policies, such as the French recommendation in 1866 that pilgrims from Mecca be forced to return via overland routes through the desert. This ensured that ‘the cholera— and those who carried it—would not survive’ (Hamlin 2009: 142–3). These new regulations, though, suffered from the same lack of coordination and inconsistent application that led to calls for international cooperation in the first place. While the conferences themselves did not result in international treaties, they did provide the opportunity for states to meet to discuss cross-border health issues. This, in and of itself, was an innovation. It shifted the terms of debate about health, making it an issue that deserved government attention and could benefit from international coordination. The conferences encouraged the international community to recognize that it could be worthwhile for states to collaborate on these sorts of issues. Repeated meetings allowed for the exchange of information, the opportunity for government representatives to build ties among themselves, and foster the most nascent sense of international obligation to address health concerns. It enabled and facilitated the sort of socialization processes that are of crucial importance to the growth and development of statecraft within international society. The repeated conferences also helped to set the stage for creating intergovernmental organizations specifically designed to address health issues. Delegates to the 1874 ISC proposed the creation of an International Commission on Epidemics. This organization would be headquartered in Vienna, have scientific representatives from all of its member-states, study disease outbreaks, and oversee the application of quarantine policies—but the proposal fell victim to the same sorts of disagreements that scuttled negotiations for 55

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an international treaty. Seven years later, the ISC revived the idea of an international health organization, but proposed the creation of two interlocking organizations (one based in Vienna, the other based in Havana) that would oversee their respective hemispheres (Borowy 2009: 26). While neither proposal came to fruition, they evince the slow evolution of thinking within international society around the idea of health and the collective responsibility to address it. Finally, in 1892, the assembled delegates to the ISC in Venice came to an agreement. The resulting International Sanitary Convention permitted limited quarantine measures and medical inspections for ships passing through the Suez Canal carrying Muslims going to and from Mecca for the annual hajj (Howard-Jones 1975: 45). The scope of this treaty was incredibly narrow and applied to only a small sliver of potential cholera cases—but it was a start. Howard-Jones describes this first agreement as a ‘landmark in the history of international cooperation in matters of public health’ (Howard-Jones 1975: 64). It also enabled future cooperative efforts. At a follow-up conference the succeeding year in Paris, states agreed to expand the 1892 agreement to cover overland movement and increase the range of medical inspections. In 1897, states moved beyond a narrow focus on cholera to include plague as a reportable disease (McCarthy 2002: 1111). Subsequent conferences continued to expand the list of diseases covered by the International Sanitary Convention to include yellow fever, smallpox, typhus, and relapsing fever (Fidler 2005: 330). These earliest conventions firmly rooted their logic in a commercial imperative. The Convention’s Preamble explicitly states that the signatories had ‘decided to establish common measures for protecting public health during cholera epidemics without uselessly obstructing commercial transactions and passenger traffic’ (Fidler 2005: 329). In so doing, it obligated states to report outbreaks to each other, maintain adequate public health capabilities at points of entry and exit, and agree not to introduce measures more onerous than those prescribed by the International Sanitary Convention (Fidler 2005: 329). Even with its limited scope, the International Sanitary Convention began the process of inculcating a sense that cross-border health qualifies as an issue on which states could and should cooperate. While not yet evidence of the emergence of an institution within international society in the closing years of the nineteenth century, the negotiation processes inaugurated the efforts to capture the normative order and bring a sense of order to international society within the health realm. It fostered socialization processes that would pay off later and contribute to developing shared understandings among members of international society. It also began the process that would eventually evolve into the IHR. 56

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The League of Nations Health Office In the years after World War I and with the efforts to create the League of Nations, there was a general sense that there should be an international organization specifically devoted to health. The ISCs had fostered a degree of collaboration on health matters, but they happened on an ad hoc basis and lacked any real permanence. They were too slow and inflexible to deal with either emergent health crises or the rapid increase in scientific information. Furthermore, the increased ease of travel and communication among countries made it more feasible to create a truly international health organization (Borowy 2009: 13–14). The world’s first international health organization, the International Sanitary Bureau (now known as the Pan American Health Organization), began operations in 1902, but its mandate was geographically limited to the Americas and it lacked much in the way of personnel or resources (Borowy 2009: 26). There was also the International Office of Public Hygiene (OIHP), created in 1907 in Paris, but its remit focused primarily on data collection rather than programme implementation (Howard-Jones 1981: 468). Proponents saw a need for an organization that could take a more pro-active approach to health, provide a permanent bureaucratic and institutional framework, and operate with a global mandate. Once the League of Nations began operations, creating a health organization emerged as one of the its early objectives. At the first meeting of the Assembly of the League of Nations in late 1920, the delegates adopted a report that called for it to absorb the already existent OIHP (with its consent) in order to create a new International Health Organization (Howard-Jones 1975: 22). As the delegates envisioned it, this new organization would engage in direct technical cooperation with member-states and actively work with national health ministries. It would establish international standards for health and health care. It would also promote cooperation among public health officials around the world and collaborate with national and international bodies, and NGOs to promote the general health. This represented a significant shift in existing practice. It combined existing theories of what constitutes health, bringing together absence-of-disease, social, and political frameworks that were then popular. It would not only collect and share relevant scientific information, but it also envisaged health as a crucial building block for the re-emergence of peace and security in the post-World War I era (Borowy 2009: 24–5). Those early negotiations failed to create a new organization, even though many who were active in the negotiations had also been active in OIHP. Part of the problem was geopolitical. Though ostensibly international in scope, OIHP was seen as largely a French organization; it was based in Paris, used French as its language of communication, and had close connections to the French government. The efforts to create a new organization were largely 57

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backed by the British government, reflecting that country’s diplomatic strength, the personal enthusiasm for the project among a number of its negotiators, and geopolitical rivalries (Borowy 2009: 60–1). These tensions stopped the merger negotiations, but they gave rise to efforts to create an entirely new international health organization. In 1922, the LNHO began operations, but it faced early controversies. Some delegates questioned the wisdom of creating such an ambitious new organization at a time when the League of Nations lacked the funds to adequately support its operations. LNHO officials assuaged concerns by assuring worried representatives that they were in negotiations with the International Health Division (IHD) of the Rockefeller Foundation (RF) to fund substantial portions of its activities (Youde 2012: 23). Founded in 1913, the IHD of the RF played a major role in encouraging international cooperation on public health issues and funding many such programmes. During the nearly four decades the IHD existed, it operated in more than eighty countries and ‘was arguably the world’s most important agency of public health work’ (Farley 2004: 19–20). At the time, RF was the world’s wealthiest philanthropic organization. John D. Rockefeller Sr, the wealthiest man in the United States at the time, signed over 72,000 shares in Standard Oil to his son John D. Rockefeller Jr, to endow the RF (Farley 2004: 3). RF’s mission was: To promote the well-being and to advance the civilization of the peoples of the United States and its territories and possessions and of foreign lands in the acquisition and dissemination of knowledge, in the prevention and relief of suffering, and in the promotion of any and all the elements of human progress. (Fosdick 1952: 15)

The Rockefellers linked health to this mission. They believed that philanthropies could play a unique role in fostering the sort of cross-border health cooperation that ‘national governments cannot undertake’ but ‘are important for the health of the people of all lands’ (Weindling 1997: 269). They also saw good health as fundamental for greater international economic and political stability. Frederick Gates, who served as John D. Rockefeller Sr’s philanthropic advisor, remarked, ‘Disease is the supreme ill of human life, and it is the main source of almost all other human ills, poverty, crime, ignorance, vice, inefficiency, hereditary taint, and many other evils’ (Brown 1979: 128). From these beginnings and subsequent donations from the Rockefeller family, IHD spent $18–25 million per year to advance international health causes (Farley 2004: 19–20). IHD’s involvement and interest in international health work resonated with the emergent international attitudes towards cross-border health cooperation. At the same time, critics alleged that the Rockefeller family had ulterior motivations for creating the foundation. Rockefeller Sr had created Standard 58

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Oil in 1870. The corporation brought Rockefeller incredible wealth, but it was also the target of significant criticisms. Ida Tarbell published her muckraking investigation of the company, The History of the Standard Oil Company, in 1904, exposing the company’s shady practices. Seven years later, the US Supreme Court declared Standard Oil an illegal monopoly and ordered it be split into thirty-four different companies (Weinberg 2008). The RF, critics argued, simply tried to counteract the family’s negative public image and poor press reports (Brown 1979: 50), though early supporters strenuously deny that the foundation’s creation was solely a public relations move (Fosdick 1952: 4). After World War I, IHD began health programmes in a number of European states. It opted to work directly through national governments because ‘protecting a community against disease must be accepted by a government as its own primary responsibility’ (Lancet 1927: 40). Instead of being a direct service provider itself, IHD supported relevant scientific research and encouraged social reforms that could promote both better health and democracy. It quickly realized, though, that it would need an organizational partner in order to adequately carry out its mission and effectively disseminate new information widely and respond to the new discoveries its research found (Weindling 1993: 253–4). The timing was fortuitous for both IHD and LNHO. IHD agreed to support LNHO, and it provided the new organization with its first grant of nearly half a million dollars in 1922. Over the next fifteen years, IHD funding allowed LNHO to support an epidemiological intelligence service, facilitate international exchange programmes for public health officials, and employ field staff (Dubin 1995: 72). The external funding became increasingly important when the League of Nations capped its own direct budgetary support for LNHO at one million Swiss francs in 1925. The League relaxed the cap in 1929, but this move coincided with the onset of the Great Depression and the decreased ability of national governments to support LNHO financially. The IHD grants allowed LNHO to maintain and expand its operations despite its parent organization’s fiscal austerity. ‘These grants were a pittance in the [Rockefeller] Foundation’s total public health budget,’ Dubin writes, ‘but they were a life-line for [LNHO director Ludwik] Rajchman’ (Dubin 1995: 72). Under the arrangement between the two organizations, IHD agreed to take a hands-off approach to specific programmes and policies, and LNHO pledged to pursue financial support from other sources (Weindling 1997: 270). Despite LNHO’s ambitions, it could not fulfil all of its desires. It lacked the financial support or the personnel to create the extensive array of programmes it desired, and it found it difficult to navigate the simultaneous international tendencies of xenophobic nationalism and a desire for greater cross-border cooperation (Borowy 2009: 17). During World War II, its operations stopped almost entirely because it had no money and its personnel could not travel 59

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safely. After the war’s end, its parent organization disappeared, thus imperilling LNHO’s continued existence. Even with the significant financial limitations and the intense constraints on its operations due to the larger geopolitical environment, LNHO embodied yet another evolutionary step within international society’s changing attitudes towards cross-border health. While by no means unanimous or a wholly shared normative standard, the willingness of states to join and work together within an international organization illustrates greater development of a collaborative attitude towards global health. LNHO’s relationship with IHD may have been borne in part by financial necessity, but it also highlighted an early recognition of the valuable potential role for non-state actors in addressing global health within international society.

The World Health Organization As World War II wound down, negotiations began for a new international organization that would promote international peace and security and avoid the mistakes of the League of Nations. The United Nations Conference on International Organization brought together representatives from the Allied nations in San Francisco in April 1945 to finalize the process of writing a charter for the new United Nations. Over the course of the negotiations, health received a fair amount of attention from the delegates. The UN Charter makes reference to the organization’s need to address health issues in four different parts, particularly in Chapters 9 and 10 on economic and social cooperation (United Nations 1945). The delegations from Brazil and China went even further, putting forward a resolution that specifically called for the creation of a new international health organization. The resolution passed unanimously (Shimkin 1946: 281). The resolution led to the holding of the International Health Conference the following year in New York. Before the conference met, a smaller group of states drew up a draft constitution for the new health organization based on proposals from France, the United Kingdom, and the United States (Lee 2009: 13). The International Health Conference included delegates from all UN member-states, an additional sixteen non-member-states, and a variety of private and intergovernmental organizations like the RF and the Pan American Sanitary Bureau (as the International Sanitary Bureau had renamed itself) (Shimkin 1946: 281–2). LNHO and OIHP also sent representatives, as the conference’s outcome would determine their fates (Sharp 1947: 510). Some within OIHP argued that it could and should remain its own organization, but such arguments fell apart when states declared they were unwilling

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to support both WHO and OIHP (Howard-Jones 1978: 79–81). The assembled delegates decided to absorb and take over the functions of both LNHO and OIHP, and a number of the early leaders of the new WHO came from these groups. Regional organizations like the Pan American Sanitary Bureau were incorporated into WHO’s structure, but they retained a high degree of autonomy and could determine their own agendas (Lee 2009: 3–4). This arrangement was designed to both provide WHO with greater on-the-ground connections with member-states while also encouraging ‘common action based on mutual consent’ (Shimkin 1946: 282). Since WHO was the first specialized agency created by the United Nations, the decisions that its founders made would set future precedents. This became particularly important in relation to deciding who could join the organization. Debates focused on whether territories or states who were not members of the United Nations could join WHO. There was also a question of whether membership in the United Nations automatically led to membership in WHO. Ultimately, the delegates came down in favour of membership universality: all states who joined the United Nations could join WHO unless they specifically opted out. States that were not part of the United Nations and territories could also join WHO, although only as associate members (Lee 2009: 21). This decision thus encouraged a broad conception of who could play a role in fostering greater international health cooperation. Despite the relative speed with which WHO’s Constitution was written, its operational beginnings were significantly delayed. The Constitution of WHO opened for signature and ratification on 22 July 1946, and it needed twentysix ratifications to come into force. It was not until 7 April 1948 that it met this requirement. Lee argues that the delay was a reflection of larger debates about internationalism in the aftermath of yet another devastating war and the tensions developing as part of the emergent Cold War (Lee 2009: 14). WHO was caught up in a larger debate over whether international organizations could or should operate in a technocratic, apolitical manner as suggested by Mitrany (Kamradt-Scott 2015: 22–3; Mitrany 1946). In many ways, this debate presaged the distinctions between pluralism and solidarism. States debated with one another over whether WHO’s mission was overly solidarist and whether the organization would allow states to retain their pluralist prerogatives. It is important to keep this reality in mind, as it reflects the fact that progress and evolution within international society is not entirely linear. While there may have been a growing consensus about the value of health cooperation, that does not automatically translate into a willingness by states to cede their authority or share sovereignty with others. This debate continues into the current era, as will be described in Chapter 4’s discussion of WHO’s contemporary operations.

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Health for All by 2000 While international society has made progress towards incorporating a more expansive idea of the need and value of cross-border health cooperation, that does not mean that this process operates without resistance. It is possible for elements of international society to push too far and promote normative standards that go too far beyond what members are willing to accept. It can be too solidarist at times when international society has more of a pluralist bent to it. This is the experience of the movement that started in the late 1970s called Health for All by 2000. Health for All by 2000 emerged out of an international conference in September 1978. Three thousand delegates from 134 countries and sixtyseven different international organizations convened in Alma-Ata, USSR (now Almaty, Kazakhstan) for the International Conference on Primary Health Care. The conference, co-sponsored by WHO and the United Nations Children’s Emergency Fund (UNICEF), was the first ever held specifically devoted to the idea of primary health care (PHC). PHC encompasses care that is essential, evidence-based, socially acceptable, universally available, affordable, and addresses the whole range of preventative, promotive, curative, and rehabilitative services. It also takes into account the wide range of services necessary to promote good health, like clean water, access to sanitation services, good nutrition, and education. It essentially seeks to put the idea of a right to health into practice in any situation in a manner that is sensitive to community interests and socio-economic conditions (Skolnik 2016: 105). It aims to turn the social determinants of health into policy, and it builds on the links between health and human rights referenced in the Universal Declaration of Human Rights and the International Convention on Economic, Social, and Cultural Rights in a practical manner. While much of the rhetoric around the conference emphasized PHC’s practical benefits, implementing such a programme would entail a radical shift in international society’s understanding of both health and its collective obligations to each other. In many ways, the changes entailed in embracing PHC are similar to those advocated by Vincent in his call for a basic right to subsistence within a global human rights system. The interest in promoting this fundamental shift emerged out of larger changes occurring within the international realm. The 1960s and 1970s saw a wave of decolonization and liberation movements, and the new governments that took control frequently promised better health and health care to their citizens. While there were positive moves in this direction, services were typically concentrated in urban areas and unavailable in rural communities (Hall and Taylor 2003: 18–20). At the same time, there was a growing chorus of voices arguing that improving health care in developing countries was not simply about transferring technologies from the West. Instead, proponents 62

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called for integrating health into larger social development schemes in a holistic manner that reflected the unique contexts of local communities and adapted to particular needs (Cueto 2004: 1864–5). The idea was to focus on a ‘bottom-up’ approach to health care that focused less on expensive technologies and building hospitals in large cities and more on developing systems that would address local needs (Magnussen et al. 2004: 168). China, Tanzania, and Venezuela were held up as models for other countries, as they created programmes that provided basic, yet comprehensive, PHC to a large portion of their populations by successfully blending local and Western traditions to provide preventative and curative services (Cueto 2004: 1865). Halfdan Mahler, then the Director-General of WHO, drew upon these experiences and his own previous work in developing countries to encourage the development of a universally agreed broad framework for providing PHC services. At the conclusion of the conference, the attendees unanimously adopted the Declaration of Alma-Ata. It identified eight crucial components of PHC: • • • • • • • •

Providing education on health concerns Promoting proper nutrition Ensuring access to clean water and proper sanitation Providing maternal and child health care, including family planning Immunizing populations against major infectious diseases Preventing and controlling local endemic diseases Providing appropriate treatment for injuries and illness Providing access to essential drugs. (World Health Organization 1978)

To put these ideas into practice, WHO came up with specific goals, including: • Spending at least 5 per cent of a country’s gross national product on health • Ensuring at least 90 per cent of children are at a weight appropriate for their age • Providing safe water either at home or within a fifteen-minute walk • Providing adequate sanitary facilities at home or in the immediate vicinity • Making trained personnel available to attend to pregnancy and childbirth • Making childcare available for children up to at least one year of age. (Hall and Taylor 2003: 18) The idea was that any country meeting these standards would be able to provide essential health care to the majority of the population at a level that was not cost prohibitive and respected the government’s sovereign right to self-determination. This, in turn, would allow international society to recognize the larger goal embodied in the slogan Health for All by 2000—and do so 63

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in a way that overcame the political and economic divisions of the Cold War. It redefined PHC as a public good and one that the market could not adequately provide, putting the onus on states to ensure its provision. It also meant that developed states had an obligation to proactively assist developing states to achieve this goal (Youde 2008: 422). Despite the enthusiasm of the conference delegates, international society as a whole did not embrace PHC and the behavioural and normative expectations contained therein. Governments in developed states cast doubt on the ability or willingness of developing states to meet the standards required of PHC. Some decried PHC as second-best health care that would prevent people from accessing more specialized care as needed. Health for All by 2000 operated as a rhetorical strategy, but it was not backed by the actual behavioural or policy change necessary to put the idea into practice (Hall and Taylor 2003: 18). The supporters of Health for All by 2000 typically came from national health ministries, but such ministries frequently had limited sway within national government structures and were disparaged as political backwaters (Vaughan et al. 1985). They lacked the ability to foment larger policy changes, and they were frequently derided as being merely technocratic. Economic conditions at the time also made it difficult for states to simply maintain their existing foreign aid outlays. The likelihood of increasing them was next to nil (People’s Health Movement et al. 2005: 59–60). Further, calls for PHC ran counter to the emergent neoliberal policy agenda in a number of Western states (Thomas and Weber 2004). When Mahler praised the Soviet Union as ‘a pioneer . . . in placing health in the forefront of social goals’ (Heyward 1978), American officials in particular saw this as evidence of a link between PHC and communism and proof that Northern and Southern interests were too far apart (Murphy 1984: 126). In reaction to PHC, developed countries instead proposed to emphasize selective primary health care (SPHC)—a model that concentrated on providing services primarily to children under the age of five (Walsh and Warren 1979). PHC’s advocates criticized SPHC for having too narrow a focus, removing a sense of agency from poor persons to make decisions about their own health care needs, and betraying the core concepts of PHC (Wisner 1988). In such an environment, the idea of PHC as a core element of global health governance failed to take root. PHC still had its advocates, but their message did not resonate with the larger community and did not become a new shared expectation for international society. The failure of Health for All by 2000 to resonate with international society shows the limits of global health governance and the expectations it could alter. It was a very solidarist programme that found itself stymied by some very pluralist interpretations of international society.

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International Health Regulations The IHR have their origins in the ISCs that began meeting in the midnineteenth century to discuss coordinating quarantine policy described earlier in this chapter. Since the first agreement came into effect in 1892, the international community has continued to revise and expand the notion of notifiable diseases, the role of information collection and dissemination to reduce the severity and extent of disease outbreaks, and the value of international cooperation to address cross-border health concerns. Their evolution shows the changing value of disease surveillance within the broader framework of global health governance, but also demonstrates the limitations that exist. When the Constitution of WHO came into force in 1948, one of the new organization’s first responsibilities was to coordinate and oversee the mishmash of international sanitary conventions and treaties. In 1951, WHO combined twelve different existing treaties into one single document—the International Sanitary Regulations (ISR). The ISR laid out five basic requirements for all member-states to follow with regard to disease surveillance and reporting. First, they identified six notifiable diseases: smallpox, cholera, typhus, yellow fever, relapsing fever, and plague. Second, they required governments to report any human cases of these notifiable diseases to WHO. Third, states had to establish hygiene monitoring procedures at entry and exit points, like border crossings, ports, and airports. Fourth, states retained the discretion to require travellers to present health and vaccination certificates prior to entering the territory. Finally, the requirements within the ISR were the maximum measures allowed under international law (Gostin 2004: 2623). The ISR were renamed the IHR in 1969, the same year typhus and relapsing fever were removed from the list of notifiable diseases. Subsequent revisions changed the procedures for dealing with cholera in 1973 and removed smallpox from the list of notifiable diseases in 1981. By the 1990s, the IHR were mired in controversy. Critics called the treaty irrelevant to the health challenges facing most countries and stuck in the past. After the 1981 revisions, they applied to only three diseases—cholera, yellow fever, and plague—and had no applicability to new diseases like HIV/AIDS or Ebola. Developed states took less of an interest in the IHR because they had largely eliminated the remaining notifiable diseases from within their own borders. States ignored their surveillance and reporting requirements out of fear that reporting a disease outbreak would lead to negative repercussions. The surveillance system was entirely passive, waiting for an outbreak before it was set in motion instead of proactively seeking out cases to stop an outbreak before it got going. It was also entirely state-based; WHO could not receive reports from non-state actors—even if a government refused to acknowledge

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that a disease outbreak was happening within its borders (Youde 2010a: 154–60). The IHR were outmoded, and that reality undermined their ability to operate as an effective element of global health governance. Efforts to revise the IHR began in 1995 with the passage of World Health Assembly Resolution 48.7. This resolution directed the WHO Director-General to revise the IHR to make them more meaningful and relevant to the contemporary environment. As the discussions began in the late 1990s, the ideas about how the IHR could best address infectious diseases began to shift. There was a move away from specific notifiable diseases and towards new models that would allow for reporting based on symptoms and effects of illnesses, thus broadening the potential range of diseases reported to WHO. Other discussions revolved around allowing WHO to receive outbreak reports from non-state sources and creating a special category for outbreaks that posed significant cross-border effects (Davies et al. 2015: 32–3). By 2001, WHO abandoned the idea of simply updating the existing IHR and instead decided that they required a wholesale rewriting. The new version would not only put greater responsibilities on member-states with their surveillance and reporting requirements, but would also grant new duties and responsibilities to WHO. The organization would be able to act based on reports from nonstate sources and could publicly name and shame states that failed to meet their requirements. WHO would also need to take a more proactive response to outbreak reports and play a more active coordination and dissemination role (Davies et al. 2015: 38–9). The revision efforts took on a new degree of urgency in the wake of the SARS outbreak in 2002 and 2003. The epidemic provided a vivid real-world demonstration of why the IHR needed to undergo massive changes. It involved a brand new pathogen. Its rapid international spread was directly connected to international travel. The outbreak had numerous economic and political effects on countries reporting sustained disease transmission. Some governments, like the People’s Republic of China, initially refused to confirm the outbreak or cooperate with WHO (Price-Smith 2009: 152–4). The outbreak inadvertently distilled all of the fears about the weaknesses of the existing IHR into one single outbreak and highlighted the overwhelming need for a massive change. This exogenous shock propelled the international community into action and gave a sense of urgency to the need for a new treaty. Finally, in 2005, the new version of the IHR, referred to as IHR (2005) to distinguish it from earlier versions, was ready for WHO member-states to vote on at the World Health Assembly. The IHR (2005) required states to develop and maintain round-the-clock disease surveillance systems and designate a National Focal Point to immediately report relevant disease outbreaks to WHO. They also moved away from a disease-specific reporting system to an ‘all-risks’ approach that made the need to report an outbreak dependent upon 66

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the potential effects of the disease and the likelihood of international spread. They empowered WHO to act based on reports from non-state actors and allowed WHO to publicly call out governments for their noncompliance (Davies and Youde 2015b). The World Health Assembly approved the IHR (2005) at its 2005 meeting, and the new regulations came into effect in 2007 (World Health Organization 2008: 36–7). The promises of the IHR (2005) have not matched its operational realities. The new disease surveillance and reporting requirements came without any financial assistance for setting up and maintaining the new systems. As a result, many developing countries have found it difficult to meet their surveillance requirements for both financial and technical capacity reasons (Davies et al. 2015: 126). Even though the IHR (2005) say that states should not introduce trade and travel restrictions in the face of a disease outbreak that go beyond WHO’s recommendations, the experience of H1N1 and Ebola both show that states do not always abide by these regulations (Davies et al. 2015: 105–6). While the IHR (2005) theoretically give WHO more power and authority in the midst of a crisis, the organization itself lacks the resources or political power to act as confidently and authoritatively as intended (Davies 2010: 152). As a result of these identified shortcomings, a number of the recommendations for reforming WHO in the aftermath of the Ebola outbreak have suggested ways to make the IHR (2005) more functional and WHO more responsive to the Regulations. The evolution of the IHR demonstrates the willingness of international society to understand a broader conceptualization of cross-border health cooperation and the further institutionalization of these ideas. It also highlights the variety of forms and actors involved in various elements of global health governance. The IHR have moved from being strictly state-based and without a patron organization to incorporating a wide variety of actors and working in coordination with states and international organizations. At the same time, there remain limits on the IHR (2005)’s efficacy due to ongoing debates within international society about funding and responsiveness.

The Global Fund to Fight AIDS, Tuberculosis, and Malaria As mentioned previously, two of the hallmarks of the recent evolution in global health governance are its incorporation of a wider variety of actors and the increased level of resources available to support cross-border health programmes. Perhaps no organization better embodies this shift and the associated changes in the normative expectations of international society when it comes to global health matters than the Global Fund. The Global Fund was purposefully designed to be something new both to better take 67

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advantage of the current political and economic climate and to offer an innovative structural design for an international organization. Rather than implementing programmes itself, the Global Fund operates solely to fund projects designed and owned by states. It receives funding from both governments and private sources. It explicitly requires the projects it funds to incorporate civil society organizations in a meaningful way. ‘This partnership between governments, civil society, the private sector, and affected communities,’ Rowden writes, ‘represents a new approach to international health funding’ (Rowden 2009: 19). By operating outside the UN system, it has greater opportunities to collaborate with a wide variety of actors and create its own relationships without being constrained by prior practice or existing regulations (Lisk 2010: 98). The impetus for creating the Global Fund emerged out of the 2000 Group of Eight (G8) meeting in Okinawa. This was the first time that the G8 included health on its agenda, and the assembled leaders recognized that poor health threatened their other international development goals. At the conclusion of the meeting, the resulting communiqué stated, ‘Only through sustained action and coherent international cooperation to fully mobilise new and existing medical, technical, and financial resources can we strengthen health delivery systems and reach beyond the traditional sources to break the vicious cycle of disease and poverty.’ The same document later stated that the group would convene a separate conference to create a new organization to ‘harness our commitments’ to increasing the resources available for global health. In particular, they cited a need to develop a new and ambitious strategy to address HIV/AIDS, tuberculosis, and malaria (Ministry of Foreign Affairs of Japan 2000). By calling for a new organization, the G8 countries implicitly recognized that WHO was not able to address these challenges under its current structure and operational capacities. They also made reference to the need for country-owned development strategies as opposed to those introduced and overseen wholly by outside actors and the need for greater collaboration with civil society and private actors in order to develop comprehensive approaches to tackling problems as massive as new and resurgent infectious diseases. The following year, the Organization for African Unity (OAU) held its own conference on the special challenges HIV/AIDS, tuberculosis, and malaria posed to its member-states. While the assembled states pledged to increase their own health budgets, they also called on wealthier states to ‘complement our resource mobilization efforts to fight the scourge of HIV/AIDS, tuberculosis, and other related infectious diseases’ by creating a dedicated fund of US$5–10 billion for such programmes (Organization for African Unity 2001). This momentum found expression in the 2001 United Nations General Assembly’s Special Session on HIV/AIDS. States affirmed their willingness to 68

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create a new international funding mechanism for HIV/AIDS that would make US$7–10 billion available to low- and middle-income countries with high HIV infection rates. There was a simultaneous call for high-income states to pledge 0.7 per cent of their gross national products for overseas development assistance and to offer debt reduction to the most heavily indebted states (United Nations General Assembly 2001). The next month, in July 2001, formal efforts got underway to create the new Global Fund. Approximately forty delegates, representing donor states, recipient states, civil society organizations, international organizations, and the private sector, met in Geneva to create a new sort of partnership that could combine the collective strengths of different types of international actors to raise and distribute funds for controlling three key infectious diseases. In January 2002, the Executive Board of the Global Fund met for the first time, and the Fund distributed its first grants to thirty-six different countries three months later (Bartsch 2007: 149–51). Between its founding and the end of 2015, the Global Fund distributed approximately US$30 billion in grants and saved 19.6 million lives. This includes reducing AIDS deaths by more than 40 per cent in countries where it has provided funding, new HIV infections by 36 per cent, tuberculosis deaths by 29 per cent, and malaria deaths by 48 per cent (Global Fund to Fight AIDS, Tuberculosis, and Malaria n.d.). The Global Fund is not a programmatic agency. Instead, the Global Fund exists solely to fund grant applications from states, and these applications must incorporate a wide range of government and civil society actors. In this way, the Global Fund aims to support country-owned projects designed by groups who understand the local dynamics facing a particular country and can draw on the collective wisdom of a variety of actors to implement the strategies developed. The grant applications themselves come from Country Coordinating Mechanisms (CCMs) that have been established in each recipient state. At least 40 per cent of the representatives to CCMs must come from civil society organizations, and the civil society organization representatives should include a presence of people with HIV/AIDS (Harman 2010: 104). Since beginning its operations, the Global Fund has achieved two key successes. First, it has become an increasingly important multilateral channel for HIV/AIDS, tuberculosis, and malaria. It has distributed approximately US$19 billion for HIV/AIDS programming, particularly in the areas of treatment and health systems strengthening. The Global Fund is the second-largest channel of HIV/AIDS funding after the US government, and is responsible for 16.6 per cent of all such funding between 2002 and 2016 (Institute for Health Metrics and Evaluation 2017: 47). It is even more prominent in the areas of tuberculosis and malaria, as it is the largest single funding channel in both areas by a substantial margin. The Global Fund has provided 44.3 per cent of all malaria funding between 2000 and 2016, with an amount totalling 69

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US$10.4 billion (Institute for Health Metrics and Evaluation 2017: 54). For tuberculosis, the Global Fund is responsible for almost half of all funding between 2000 and 2016. Of the US$15 billion in development assistance for health specifically targeted towardss tuberculosis, the Global Fund distributed US$6.5 billion (Institute for Health Metrics and Evaluation 2017: 57–9). The funding from the Global Fund is particularly important because the organization operates according to the ‘additionality principle’. Grants from the Global Fund are not subtracted from other funding commitments and should instead fill gaps not covered through other funding mechanisms. In other words, Global Fund grants are deliberately designed to increase the amount of money going to a country in order to address HIV/AIDS, tuberculosis, and malaria (Lisk 2010: 102). Second, it has diversified the range of actors who are formally cooperating with one another to address cross-border health issues. Its application process had made the rhetoric of cooperation more of a reality. This collaboration extended to increasing the likelihood that the programmes included in a grant application resonated with local conditions. It fostered a ‘demand-driven’ model that provided an opportunity for more voices participating in the processes of defining that demand (Bartsch 2007: 161–3). The shortcomings of the Global Fund relate to the disjunctures between its aspirations and its realities. The organization has indeed increased the amount of funding available for HIV/AIDS, tuberculosis, and malaria, but it has seen its funding from donor states and other organizations fall short on a number of occasions. Because the Global Fund is wholly donor dependent, any shortcomings in the contributions it receives have a very direct effect. During the 2004–5 biennium, the Global Fund’s contributions fell short of its funding requirements by $2.3 billion, or 38 per cent (Buse and Harmer 2007: 266). Non-governmental organizations (NGOs) may have roles within CCMs, but practice shows that government ministries tend to dominate CCMs and that NGOs frequently lack the resources to participate in the Global Fund’s processes as equals. Furthermore, even though there are specific mechanisms for incorporating NGOs from the Global South, wealthy NGOs from the Global North continue to play an outsized role (Brown 2009: 171–2). The organization focuses on only three diseases, which raises the possibility of distorting the health agendas of the very countries that the Fund wants to take ownership of these grant programmes (Davies 2010: 53). The vertical nature of the Global Fund’s organizational mandate contrasts with the calls for more system-wide, horizontal interventions. Ooms et al. have argued that the Global Fund itself needs to evolve away from its exclusive focus on three diseases and towards being a more general Global Health Fund (Ooms et al. 2008). In many ways, the successes and shortcomings of the Global Fund reflect the broader trends in global health governance within international society. It wants to incorporate more actors, but it runs into difficulties putting this into 70

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practice. It increases the amount of money available, but its funding still falls short of its needs. At the same time, the Global Fund represents the continual evolution in how international society thinks about global health governance and its place within a larger framework of a moral responsibility to assist those in need beyond national borders.

The Bill and Melinda Gates Foundation It is nearly impossible to consider the contemporary nature of global health governance without discussing the BMGF. Founded in 1999 by the founder and chair of Microsoft and his wife, BMGF is the world’s wealthiest philanthropic organization. At end of 2015, its endowment stood at nearly $40 billion, and it distributed $4.2 billion in grants in its different funding areas during 2015 (Bill and Melinda Gates Foundation 2016). BMGF’s Global Health Program made more than $1.1 billion in grants in 2015, and the closely related Global Development Program made another $2 billion in grants. By the Institute for Health Metrics and Evaluation’s calculations, of the $37.6 billion in development assistance for health available during 2016, BMGF contributed $2.9 billion—7.8 per cent of the global total (Institute for Health Metrics and Evaluation 2017: 19). Only the governments of the United States and United Kingdom provided more. Global health is one of BMGF’s target areas, and its wealth gives the organization the ability to have a significant influence in the shape and direction of global health programmes—even beyond the specific grants it provides. For better or worse, its financial clout can have a large effect on the global health agenda by elevating certain issues. Further, Bill and Melinda Gates themselves have become highly prominent in the global health community and frequently meet with international policymakers to discuss global health policy and practice. They receive attention that other private individuals simply would not. By turning their focus to a particular issue, they can alter the conversation. Their prominent support of Rotary International’s polio eradication campaign, for example, has brought a large amount of attention and debate to that issue. BMGF’s endowment comes largely from two sources: Bill and Melinda Gates themselves and Warren Buffett. Gates’ wealth from Microsoft has allowed the foundation to make significant investments in global health, but BMGF’s grantmaking ramped up in 2006. That year, Warren Buffet pledged to give BMGF 10 million shares of Berkshire Hathaway worth approximately $31 billion over multiple years with the proviso that the foundation increase its annual grants by the amount of his annual gift (Loomis 2006). Though it may seem odd that a philanthropic organization would play such a prominent role in global health, BMGF argues that its unique abilities 71

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and insights allow it to make significant and meaningful contributions. In particular, it cites its business insights, technical know-how, and focused intensity for allowing it to address problems beyond what state governments can do. That does not mean that it believes it can replace national governments; rather, BMGF argues that it can complement what states and intergovernmental organizations can do. Because it lacks the sorts of bureaucratic structures and established procedures that can slow the ability of a government or international organization to respond to global health issues, BMGF positions itself as being more nimble and able to respond to changes in the global health agenda more quickly. Further, it argues that it has an ability to work on issues over a longer term because it need not worry about elections and the partisan political pressures that can limit a government’s long-term planning. Bill Gates himself has argued, ‘Foundations bring something unique when they work on behalf of the poor, who have no market power, or when they work in areas like health and education, where the market doesn’t naturally work towards the right goals and where the innovation requires long-term investments’ (Gates 2009: 16). In these ways, BMGF positions itself as able to operate as a market-correcting force that can use its heft to make markets work for addressing pressing social goods. It sees itself as informally dividing responsibilities between itself and national governments. It provides relatively little support for health care infrastructure, as it sees that as the primary responsibility of states (Chen 2006: 663). Instead, it focuses its work on research and development of treatments for infectious diseases—the sort of basic science that governments find it increasingly difficult to fund themselves and that market-based actors shy away from because of the lack of earning potential. BMGF’s prominent involvement in global health has raised serious debates about the proper role of private and philanthropic actors within global health governance. In its first two years, BMGF provided more than US$400 million for AIDS projects. Peter Piot, the former executive director of UNAIDS, credits BMGF with creating a ripple effect that increased international funding from donor states for AIDS programmes worldwide. He argues that BMGF’s contributions effectively ‘sham[ed] many “donor” governments’ into increasing their donations (Cohen 2002: 2000). BMGF’s leadership in HIV/AIDS funding continues to this day. In 2014, total philanthropic giving for HIV/AIDS equalled US$617.8 million. BMGF contributed US$223.9 million, or 34 per cent, of that total (Funders Concerned About AIDS 2015: 5–6). Since the founding of the Global Fund, BMGF has also been a major funder, donating US$650 million before announcing in 2012 that it was issuing a long-term promissory note of US$750 million to support the Global Fund’s activities going forward (Global Fund to Fight AIDS, Tuberculosis, and Malaria 2016a). BMGF’s funding prowess goes beyond HIV/AIDS. During 2014 alone, it gave US$1.1 billion in grants—while WHO’s entire budget for that same year 72

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was less than $2 billion. In fact, BMGF was a the second-largest voluntary contributor (and largest non-state contributor) to WHO in 2014, providing the organization with $256.5 million (World Health Organization 2015a: 9). It also pledged $55.4 million to the UN system for the response to Ebola (United Nations Office for the Coordination of Humanitarian Affairs 2016). It committed more than $500 million to reduce the infectious disease burden in developing countries, and that pledge included a 30 per cent increase in its malaria funding as part of its goal to eradicate the disease by the middle of the twenty-first century (Bill and Melinda Gates Foundation 2014). It has also created matching-fund programmes to encourage more non-state actors to provide funding for global health programmes. It was through one of these programmes that BMGF pledged to match every dollar (up to US$50 million) raised by Product (RED)—a programme of specially branded consumer goods that give a portion of their profits to purchase antiretroviral drugs through the Global Fund (Blumenstein and Safdar 2016). BMGF also aims to encourage greater collection and use of data and science to improve health outcomes. It has supported the Institute for Health Metrics and Evaluation (IHME) at the University of Washington since 2007. IHME’s mission is to provide data-driven policy recommendations in order to identify the best strategies to build a healthier world (Institute for Health Metrics and Evaluation n.d.). In 2013, BMGF sponsored a competition to encourage designers to create the ‘next-generation condom’. Out of 812 entries, BMGF selected eleven winners and gave them US$100,000 each to further develop and refine their ideas—at which point they will be eligible for up to US$1 million to help bring the design to market (Belluck 2013). This is the sort of project, BMGF argues, that is unlikely to be supported by private industry, national governments, or intergovernmental organizations. BMGF’s rise in prominence has come with criticism about its role within global health governance. Four criticisms have been particularly prominent. First, because BMGF is such an important funder, it has essentially bought the silence of potential critics and drowned out competing voices. Arata Kochi, the director of WHO’s malaria control programme, wrote a memo to senior WHO staff in 2008 complaining that BMGF’s funding dominance had created ‘stomach-churning groupthink’ within the malaria research community (McNeil 2008). It funded so many researchers, he argued, that no one could dare to criticize its approach or afford to go against BMGF’s preferred strategies. Second, BMGF’s wealth comes from the very economic system that causes ill health and inequality in the first place. Its philanthropic efforts paper over the serious political, economic, and social inequalities that persist, and it fails to question the legitimacy of the system itself (Hindmarsh 2003: 12; Moran 2011: 131–3). Third, BMGF’s predilections for science and technology orient it towards approaches that may not be appropriate for local communities where the 73

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programmes would need to be implemented. The organization privileges the high-tech over local needs and understandings (Barth 2010; McNeil 2008). Finally, BMGF raises serious questions about its authority and legitimacy to drive the global health agenda. It assumes a mantle of leadership and claims legitimacy, but the origins of any such authority and legitimacy are unclear. The idea that an organization is legitimate simply because it is wealthy contradicts the standard understandings of how political authority is (or should be) conferred within contemporary international relations (Harman 2016). These issues will come up more in Chapter 4, but they demonstrate how the rise of the BMGF in global health governance has challenged many assumptions about who should operate in this space and under what circumstances.

Conclusion This chapter has traced the evolution of global health governance within international society to its current place as a secondary institution. The current conception of global health governance did not emerge fully formed during the 1990s; it is the result of a slow and gradual process that dates back at least to the mid-nineteenth century. These processes have not advanced in a linear fashion, and there have been key moments where international society has resisted certain normative and behavioural standards. Over time, though, there has been a continual institutionalization of global health governance, an expansion of the organizations involved in global health governance, a growth in international treaties obligating states to perform certain healthrelated actions, a movement away from an entirely state-centric focus, and a desire to expand the amount of resources available from the international community to address health concerns in developing states. At the same time, this historical process demonstrates that there remain areas of contestation within international society over the proper place of global health governance and its associated expectations. Global health governance has changed and evolved in order to assume its current role, but that current role is not necessarily the ideal role, nor is it necessarily the end point of these processes. While this chapter has focused attention more on the historical evolution of the global health governance system, Chapter 4 concerns the contemporary manifestations of this secondary institution. It focuses on some specific organizations and normative expectations that have emerged out of the past 150 years of change and innovation in the global health space.

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Chapter 3 detailed how the notion of global health governance has evolved since the mid-nineteenth century by looking at some of its key players and moments. It is through understanding the ups and downs of earlier iterations of global health governance that we can appreciate the contemporary manifestations of the system. To understand the successes and failures of the current global health governance system, we must then examine how the system has evolved to give us the system that we now have. The coordinated efforts and cooperative actions that occur through global health governance make sense only by looking at the organizations and actors involved in the system today. This chapter highlights some of the key broad categories of actors in the modern global health governance system. Understanding the global health governance architecture is somewhat complicated because it apparently operates under two seemingly contradictory logics: there is a plethora of actors involved in global health governance because the system is one without hierarchy, meaning that institutions can clash with one another or fail to coordinate—yet the World Health Organization (WHO) is also the constitutionally designated leader for the international community’s response to transnational health concerns. The proliferation of institutions—both in sheer numbers and in terms of the different types of organizations—also supports the idea that a proper accounting of the international society emerging around global health governance necessarily needs to include a wider array of actors in order to fully capture the totality of its activities. The institutions of global health governance have emerged specifically to help international society work together to achieve a common and collective good—or at least improve the likelihood that it can further the acceptance of its shared norms and behavioural expectations. These various organizations are both tools for helping the states in international society realize their goals and actors with a degree

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of agency and autonomy in their own right. At the same time, the increase in organizations dealing with elements of global health governance can lead to complication, confusion, and conflicts. This is less a sign of dysfunction and more a sign of the relative newness of global health governance as a secondary institution of international society. This chapter proceeds in five sections, looking at specific types of organizations from the more traditional intergovernmental organizations to newer players on the international stage like private philanthropies and NGOs. First, it turns attention to an element of global health governance that rarely gets analysed as an actor in its own right—states. States are ultimately responsible for implementing global health programmes, but their involvement in global health governance often goes overlooked. Second, it provides details about WHO and its constitutionally designated role as the international community’s leader on global health issues. Third, it discusses the role of multilateral funding agencies, such as the World Bank and the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund), in global health governance. Fourth, it highlights the emergence of public–private partnerships (PPPs) as tools to combine the comparative strengths of state-based resources and the private sector. Finally, it talks about the role of non-state and private actors, such as NGOs, prominent individuals, and philanthropic organizations.

States States are not the only actors in international relations, but international relations makes no sense without states. Curiously, though, states receive relatively little attention within the global health governance literature. Descriptions of the important elements of global health governance tend to focus on intergovernmental organizations, NGOs, and private actors, but they generally do not address the role that states play in supporting global health governance and implementing programmes. This oversight is all the more baffling when we consider how vital a role states play in the existence and maintenance of the global health governance architecture. Even with the vast increase in global health funding over the past generation, governments in low- and middle-income countries still provide more of the funding for their health expenditures than they receive in aid for health (Institute for Health Metrics and Evaluation 2016: 10). Davies notes, ‘States determine what they will financially and administratively commit themselves to, set health priorities and policies, and influence the extent to which their citizens’ health will be affected by outside actors’ (Davies 2010: 54). Donor states determine much of the global health governance agenda and 76

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provide the funding for it, and the governments of aid-recipient states retain significant powers to address health inequities among their own citizens (Davies 2010: 57–60). The intergovernmental organizations that have come to prominence in global health governance are populated by states. Indeed, it is only through the acquiescence of member-states that these sorts of organizations incorporate NGOs and other actors into the fold. It is the states that empower non-state actors to have a role in global health governance in many circumstances. States are a crucial element of global health governance. Harman goes so far as to call them ‘the primary site of global health governance’ (Harman 2012: 28). She identifies two key ways in which states play a large role in this system. First, states are the primary source for global health funding. The institutions of global health governance require money in order to operate and introduce various programmes, but they largely lack the means to independently raise funds. WHO and the World Bank are both primarily reliant upon dues and voluntary contributions. Even institutions that employ innovative financing structures, like UNITAID’s use of airline ticket taxes to raise funds for antiretroviral drugs, require the cooperation of state authorities to collect the fees and then transfer them to the organization. While non-state sources have steadily increased the amount and percentage of global health aid that they contribute, their contributions remain dwarfed by the sheer scope and size of aid that governments allocate from their treasuries for global health purposes (Harman 2012: 29–30). For every one dollar that low-income countries received in global health aid in 2015, their own governments expended $1.50. For middle-income states, governments spent $79.40 for each dollar they received in global health aid (Institute for Health Metrics and Evaluation 2016: 10). Second, because states are sovereign actors, any programmatic intervention requires the government to at least acquiesce to its presence within the country. States need not necessarily implement global health governance activities on their own; intergovernmental organizations, NGOs, and private actors can and do carry out direct health interventions in a wide variety of countries. That said, it is only through state sanctioning that such interventions can happen in the first place. Harman writes, ‘Without state infrastructure or backing . . . global health initiatives are seen to fail’ (Harman 2012: 28). This is evident in the growing attention paid to state ownership as a vital portion of good governance when it comes to global health governance (Fidler 2010b; Gostin and Mok 2009). If states do not permit global health interventions, or if they do not substantively engage with them, the likelihood of success goes down significantly. This is part of the normative expectation that exists within the emergent international society focused on global health governance. 77

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The World Health Organization The Constitution of WHO explicitly states that the organization’s primary function is ‘to act as the directing and co-ordinating authority on international health work’ and ‘to establish and maintain effective collaboration with the United Nations, specialised agencies, governmental health administrations, professional groups, and other such organizations as may be deemed appropriate’ (World Health Organization 1948: 2). This declaration explicitly positioned WHO as the lead organization in the post-war global health governance system, but its leadership role and international esteem has varied widely over the years. Two years after WHO began its operations, Allen called WHO ‘the broadest and most liberal concept of international responsibility for health ever officially promulgated’ (Allen 1950: 30). Four decades later, Goodlee reflected on WHO in decidedly more pessimistic tones: ‘People know that it exists, but few have a clear idea of what it does’ (Goodlee 1994: 1494). This sense of questioning the place of WHO within global health governance continues to this day in the aftermath of the organization’s response to the Ebola outbreak in West Africa. Osterholm and Olshaker pose the challenges facing WHO—and global health governance more broadly—in stark terms. ‘We strongly believe,’ they write, ‘that there must be a major overhaul of the WHO . . . for there to be any effective public health response to the twentyfirst-century world of infectious diseases. If that cannot be accomplished, we need to start over and come up with a new international organization or agency that can do the job’ (Osterholm and Olshaker 2017: 311). WHO occupies a unique niche within global health governance. It is not a funding agency. It is not a purely technical agency. It lacks the personnel to implement a large number of programmes or deliver emergency health care on its own. As will be discussed later, it actually has relatively little control over its own agenda because of how it receives its funding. These features place special pressures on WHO’s abilities to realize its mission as the directing and coordinating authority on international health work but without many of the tools at its disposal that would allow it to be successful. Furthermore, the rising influence of non-state actors in global health has increased the complexity of the environment in which WHO attempts to wield its influence (Hein 2016). In the current global health governance system, WHO occupies three key roles: normative leader, facilitator, and information disseminator. WHO can use its near-universal membership and legitimacy to call attention to issues and bring various actors together to talk about them. It can provide a venue for discussing and debating key global health issues. It has the linkages with governments to collect and share vital information that can both alert the international community to disease outbreaks and allow states to learn from

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others about how best to address health concerns. No other health-related organization has the reach, legitimacy, or stature to mobilize the international community. Because of the limitations it faces, though, it cannot act on these concerns independently. Mobilizing a campaign against Ebola, tobacco use, or any other health issue requires states and other organizations to put WHO’s ideas into practice. Structurally, WHO has four key components. The first, the World Health Assembly (WHA), acts as WHO’s supreme decision-making organ. Meeting every May in Geneva, each member-state sends delegates to WHA to determine WHO’s overall policy directions, receive and review reports, elect members to the WHO Executive Board, and approve the organization’s budget (Lee 2009: 24–5). WHA voting operates on a ‘one state, one vote’ principle that provides equal weight to all members regardless of economic or political power. Analysis of how member-states operate within WHA suggests that Western powers do not dominate the body’s agenda and that developing countries do indeed take advantage of the opportunities afforded them by WHA’s structure to make their voice heard in setting WHO’s agenda (Van der Rijt and Pang 2015). Other organizations and accredited NGOs may attend WHA meetings, too, but they lack voting rights. The second component, the Executive Board, oversees the implementation of the programmes and actions approved by WHA. It has thirty-four members selected by WHA and appointed to serve as individuals rather than as representatives of specific governments for three-year terms. It meets twice a year to prepare WHA’s agenda, review the proposed budget, and authorize emergency measures for WHO as needed (Lee 2009: 26–7). The third component, the Secretariat, provides the administrative and technical support for WHO. It implements the organization’s various initiatives, drafts the organization’s budget, and handles its day-to-day operations. The Director-General, WHO’s leader and chief executive officer, oversees the Secretariat’s operation and is selected by WHA for a five-year term (Lee 2009: 27). Finally, there are the six regional health organizations that work with, but (and this distinction is crucial) not for, WHO headquarters. The regional organizations technically exist independently of WHO. They direct their own operations, overseeing their own budgets and choosing their own leadership. WHO lacks the ability to compel the regional organizations to undertake specific projects, which can lead to conflicting priorities and programmatic emphases. In this way, the relationship between WHO in Geneva and the regional organizations is rather federal in its power-sharing nature—for better or worse (Youde 2012: 33–4). While the regional organizations have a high degree of autonomy, the WHO Constitution declares them to be ‘an integral part of the Organization’ (World Health Organization 1948: 12).

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WHO’s funding structures place important limitations on what the organization can actually do. Funding for WHO comes in two distinct streams. Regular assessed membership dues are the first funding stream. Dues are calculated according to a formula that considers gross national product and population size, but there has been no increase in annual dues in either real or nominal terms since 1993 (Van de Pas and van Schaik 2014). These funds go into WHO’s core budget, and WHA has the ultimate authority to determine how to allocate this money to support WHO’s various programmes and initiatives. Voluntary contributions constitute the organization’s second funding stream. These funds can come from states, private business, philanthropic organizations, or any other source. Importantly, though, voluntary contributions are unique because the donor specifies how WHO will use these funds. They can go into WHO’s general budget, and some voluntary contributions do indeed fund the organization’s general operations, but the vast majority are given with the explicit requirement that they are to be used solely for a particular project designated by the donor. As a result, WHA has no budgetary control over voluntary contributions. While these donated funds have been a part of WHO’s budget since its founding and are mentioned in Article 57 of the WHO Constitution, they have become an increasingly large part of WHO’s finances over time. During the 1970–1 biennium, voluntary contributions made up only 18 per cent of WHO’s budget. By the 1980–1 biennium, voluntary contributions comprised more than half of WHO’s budget (Lee 2009: 40). For WHO’s 2016–17 approved budget of $4.544 billion, voluntary contributions make up 79 per cent of total funding (World Health Organization 2016d: 6). Because of these increasing shifts towards voluntary contributions to WHO, WHA has a decreasing level of control over WHO’s budget. Voluntary contributions change WHO’s relationships with its members away from being broadly multilateral and instead more towards a confusing series of bilateral arrangements with leading donors. WHO may get the funding it needs in the aggregate, but it has less ability to allocate those resources as it sees fit and in accordance with its programmatic priorities (Graham 2015). This means that an intergovernmental organization ostensibly created to serve as the leader for international health efforts has an increasingly diminished ability to actually chart its own path or respond to sudden and unanticipated emergencies. Despite these challenges and limitations, WHO retains two unique advantages over other health-related actors that gives it significant heft and value within international society. First, it has near-universal membership. All members of the United Nations (with the exception of Liechtenstein) are also members of WHO. The organization also grants membership to other self-governing territories and associated states, and it has connections with most of the prominent global health-related NGOs. Second, it possesses a high degree of legitimacy. Because of its broad membership and its various 80

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opportunities for all sorts of states to participate in its decision-making processes, its pronouncements and ideas carry a certain degree of weight and value within international political discourse. The bigger questions facing WHO regard whether the structure and operating processes developed for the organization in the 1940s remain relevant for the contemporary era and the health challenges facing the international community. As will be discussed in Chapter 6, WHO’s lacklustre response to Ebola has inspired many calls for reform.

Multilateral Funding Agencies When states require additional resources to create or implement health programmes, they have two options: they can turn to bilateral donors, or they can seek funding from multilateral organizations. While WHO may be one of the leading global health governance organizations, it is not a funding agency. It can provide support and expertise, but states must look elsewhere for financial assistance. This financing arrangement has both empowered traditional multilateral funding agencies to become leading players in global health and encouraged the creation of new funding agencies. Even if these multilateral funding agencies claim their activities are solely related to funding and are not programmatic in nature, the choice of which projects to fund necessarily gives them an important programmatic element. The World Bank and the Global Fund are two of the more prominent multilateral funding agencies dealing with global health issues, and they embody two distinct types of agencies; the World Bank is a traditional intergovernmental organization with membership restricted to states and funds a wide range of development programmes, while the Global Fund draws on a wider range of financial contributors and acts solely as a programme funder for specific health projects.

World Bank The World Bank is not strictly, or even primarily, a global health institution. Its founding predates WHO, and it did not even begin to make loans for health-related programmes until the 1970s. Since that time, though, it has emerged as the world’s largest multilateral funding source for global health issues. The World Bank’s growing role in global health has attracted controversy, though, as its theoretical orientation and history of placing conditionalities on its loans has caused questions over how beneficial its efforts are. The World Bank came into being in 1944 with a mandate to support infrastructure and industrial projects as part of the post-World War II rebuilding efforts. Health and other social service concerns were not part of its agenda, 81

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in part because they failed to produce tangible, measurable, and direct returns (Ruger 2005: 62). When Robert McNamara assumed the presidency of the World Bank in 1968, he shifted its thinking to link social indicators like health to the Bank’s traditional focus on economic development (Harman 2010: 31). In 1970, the World Bank provided Jamaica with a $2 million loan to support family programmes—its first health-related loan. Since then, the World Bank has continually expanded its efforts in addressing global health by leveraging the fact that it is not strictly a health-related organization. It presents itself as a technocratic, non-partisan actor which can direct resources appropriately and based on economic data (Harman 2009b: 229). Between 1997 and 2007, the World Bank’s median annual level of total health financing was US$1.4 billion (Harman 2012: 48). By 2003, 22 per cent of the Bank’s loan portfolio went to health and social service-related projects (Ruger 2005: 61). The World Bank publicly links its funding to concrete improvements in global health. By its own accounting, World Bank loans between 2013 and 2015 immunized nearly 143 million children; gave almost 29 million pregnant women access to antenatal care; supported basic nutrition services to more than 177 million children, adolescent girls, and pregnant women; provided tuberculosis treatment for 2.6 million people; and allowed skilled health personnel to attend approximately 12 million births (World Bank 2016). The World Bank’s involvement in global health governance has provoked a fair amount of circumspection. Its financial resources outstrip those of most other global health organizations, so it has infused the sector with the money necessary to carry out many new projects. Clinton and Sridhar note the World Bank’s simple advantage within the global health space: ‘It is a bank that countries can rely on for financing their health sector, both as it is today and as they envision it for tomorrow’ (Clinton and Sridhar 2017: 196). The Bank not only has resources outstripping many other global health organizations, but because it is not dependent on annual or biannual donor replenishment drives, it can facilitate more long-term thinking than other organizations can. It has also partnered with other organizations to strengthen global health governance efforts more broadly. McNeill and Sandberg argue that one reason that organizations may trust the World Bank is that they believe that it can help promote a common good (McNeill and Sandberg 2014: 329). For example, the World Bank has partnered with WHO, the Bill and Melinda Gates Foundation, and the Global Alliance for Vaccines and Immunization (GAVI Alliance) to expand vaccine access. At the same time, its financial dominance and ideological commitments have caused critics to question whether the World Bank’s involvement in global health has been positive overall for the international community. Lloyd and Weissman criticize the World Bank’s emphasis on privatization 82

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and cost reductions for leading to a reduction in access to health services, among other social services, in developing countries (Lloyd and Weissman 2002). Nuruzzaman argues that the World Bank prioritizes market-based private health care over the public provision of health services because the former is more in line with its worldview. This, he claims, leads to a reduction in government expenditure on health services, which in turn dismantles public health systems. Such a transformation causes a systematic violation of the human rights of the poor (Nuruzzaman 2007). Hammonds and Ooms echo this critique. The World Bank’s poverty reduction strategies, they allege, make it impossible for states to fund their health systems at levels high enough to satisfy basic obligations. As a result, these policies violate the human rights treaty obligations of World Bank member-states. They describe the Bank’s attitude as ‘grow first, deal with human rights later’, which sacrifices the health of the poor to macroeconomic indicators (Hammonds and Ooms 2004). Davies highlights how states seeking World Bank funding for health-related projects must perform a cost-effectiveness analysis. This, she argues, skews priorities away from addressing the needs of the poor (Davies 2010: 44). It also reduces expenditures and staffing for hospitals, forces the introduction of user fees, and shifts responsibility of health and health care increasingly towards the individual (Harman 2012: 47). Despite this emphasis on cost-effectiveness, though, actual measures for identifying and quantifying cost-effectiveness remains controversial and unsettled even within the Bank itself (Sridhar 2007: 507–10). Critics also allege that the World Bank has usurped WHO’s leadership within global health—and that WHO has essentially colluded with the World Bank to do so because WHO lacks the resources to assert its constitutionally granted powers (Armada et al. 2001). The concerns about the World Bank’s involvement in global health go beyond its direct funding of health systems in developing countries. Lethbridge calls attention to the increasingly complex nature of World Bank financing in health-related issues, such as information technology and medical devices. By combining the World Bank’s resources with private equity funds and multinational corporations to invest in health, it becomes more difficult to perform regulatory oversight and ensure some degree of government transparency (Lethbridge 2005). The blurred lines reduce transparency and make it less likely that a government can be held accountable over whether it is promoting the health interests of its citizenry. At the same time, the Bank’s funding of HIV/AIDS programmes challenges traditional notions of sovereignty and acts as a vehicle for the Bank to try and introduce its market-based governance reforms. Instead of directly telling states that they need to make specific changes, the Bank uses its financial power and programmatic requirements, such as mandating certain institutional configurations or requiring partnerships with nongovernmental actors, to induce shifts in governance patterns that are more in 83

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line with its market-based orientation (Harman 2009a). Such processes will, in turn, advantage Western financial interests and the elites in the states where World Bank processes are implemented, and disadvantage the majority and those who most need access to these health services (Muiu 2002). The World Bank is unique because it has the ability to bring issues to the global health agenda and facilitate coordination among a diverse array of actors interested in health. At the same time, though, its neoliberal orientation and financial dominance mean that it is hardly a neutral actor and can influence decision-making in ways that align with its interests—which may or may not sync with a country’s health needs or larger concerns about human rights (Davies 2010: 48; Harman 2012: 50).

Global Fund to Fight AIDS, Tuberculosis, and Malaria Chapter 3 describes the origins of the Global Fund, but this chapter explains how its unique mandate allows it to act as an important element of global health governance. The Global Fund draws on states, NGOs, and private philanthropies for both the resources necessary for making grants and to serve on the board that allocates grants. When a country applies for a grant from the Global Fund, the proposal is evaluated by the Technical Review Panel, which assesses the proposal’s feasibility and ensures it has broad cross-sectoral participation. The Technical Review Panel consists of twenty-six members from around the world and is appointed by the Global Fund’s Board of Directors prior to the deadline for each round of submissions. After the Technical Review Panel makes its judgement, proposals then go to the Board of Directors. The Board’s twenty-two members represent donor states, recipient states, NGOs and civil society organizations, the private sector, and representatives of communities affected by the diseases. If and when the Board approves a grant, it does so initially for two years, after which the recipient state can apply for an extension of one to three years. The Board has historically approved the overwhelming majority of applications for a grant extension (Schocken n.d.). The Global Fund is entirely donor dependent for the funds it allocates. Because it is not a membership organization, it does not have the power to assess dues. Instead, it subsists on voluntary contributions from governments, the private sector, philanthropic organizations, and individuals. The Global Fund asks for support during its replenishments approximately every three years. It opened its fourth replenishment in December 2013, receiving initial commitments of US$12 billion from twenty-five governments and a variety of NGOs, including the BMGF, the United Methodist Church, the Tahir Foundation, and the Product (RED) Campaign (Global Fund to Fight AIDS, Tuberculosis, and Malaria 2013). This amount fell short of the Global Fund’s stated goal of US$15 billion, but it was still the largest amount of funding 84

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ever pledged to HIV/AIDS, tuberculosis, and malaria up to that point (Builder 2013). During the 2016 Replenishment Round, hosted by Canada, the Global Fund set a new record and raised nearly $13 billion. Officials reported that this would allow the Global Fund to save 8 million lives and prevent 300 million infections. This Round was notable for expanding the number of countries contributing and for securing a record $250 million in funding pledges from private donors (Global Fund to Fight AIDS, Tuberculosis, and Malaria 2016b). Global Fund resources have had a direct effect on scaling-up the financing available in its three focus areas. As of the beginning of 2017, the Global Fund has cumulatively provided $32.9 billion to programmes in 140 different countries. The majority of that funding—$17.1 billion—has gone to HIV/AIDS programmes, but malaria ($9.2 billion) and tuberculosis ($5.2 billion) also receive significant funding (Global Fund to Fight AIDS, Tuberculosis, and Malaria 2017). While HIV/AIDS programmes have received the most money in raw dollar amounts, the Global Fund’s contributions to tuberculosis and malaria programmes have increased the funding available to address these two diseases by a larger percentage. According to its monitoring and evaluation processes, Global Fund-supported programmes have provided antiretroviral treatment access to 8.6 million people, distributed 5.2 billion condoms, successfully treated 11 million cases of tuberculosis and 560 million cases of malaria, and distributed 600 million bed nets to prevent malaria infections (Global Fund to Fight AIDS, Tuberculosis, and Malaria 2016c). While the Global Fund has become a major international funder for global health projects, it has also attracted some controversy. In 2011, news reports alleged that officials in a number of recipient countries had pilfered funds from Global Fund grants and submitted fraudulent or forged documentation. More than two-thirds of the funds intended for anti-AIDS programming in Mauritania, for instance, were misspent, and the Fund stopped routing its grants through the Zambian government when health officials there could not document how they spent the funds (Heilprin 2011). As a result, some donor states suspended their contributions to the Global Fund until it addressed the concerns and reorganized its procedures to detect fraud. The Fund’s own investigation found $44 million in misallocated or fraudulently used funds in twelve countries, and it revamped its grant allocation and accounting processes as part of its ‘zero-tolerance’ approach to corruption (Centre for Global Development 2013: 6).

Public–Private Partnerships The sheer scope of global health issues and the amount of money needed to address them pose significant challenges to relying exclusively on states and 85

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state-based organizations within the existing global health governance architecture. Existing organizations have fallen short in their ability to coordinate actions or invest sufficient resources. Jealousy, competition, and serious disagreements about appropriate tactics have introduced inefficiencies. Disjunctures have developed between what international organizations want to do and what national and local governments believe to be most appropriate. Governments and intergovernmental organizations are seen as too slow and sclerotic to respond effectively to the plethora of global health issues. NGOs and private actors have gotten involved with the direct provision of services, but they lack official standing within global health governance. PPPs have emerged in an attempt to bridge the gap between public and private actors and have become key global health actors in their own right. PPPs developed in the mid-1990s as a strategy for addressing complex problems in developing countries that had arisen due to a combination of state and market failures (Moran and Stevenson 2014). While the exact organizational structure of PPPs varies widely, they share a common logic. PPPs combine a variety of types of actors, such as states, international organizations, NGOs, civil society groups, and the private sector, to collaborate on specific issues or objectives. They may establish their own secretariats and headquarters, or they may draw on the resources of one or more of the partners. While PPPs are not unique to global health, they have become integral to many global health policy interventions (Harman 2012: 76). They have become particularly important on issues of pharmaceutical/technological development and establishing new funding mechanisms (Buse and Walt 2000; Moran and Stevenson 2013). Prominent examples of global health PPPs include: • International AIDS Vaccine Initiative (IAVI), which brings governments, pharmaceutical companies, NGOs, and philanthropic foundations to promote the development of an AIDS vaccine and work with local communities to strategize on promoting access to the eventual vaccine (Chataway et al. 2007). • UNITAID, which works with governments, pharmaceutical companies, and NGOs to act as an international drug-purchasing facility that funds itself through innovative strategies like airline ticket taxes (Douste-Blazy and Altman 2010). • GAVI Alliance, which draws on donor states, the BMGF, and WHO, among others, to draw attention to new and underused vaccines and to make vaccination and immunization a vital part of health systems in general (McNeill and Sandberg 2014). PPPs position themselves as beneficial precisely because of their unique structural arrangements. Their formation is driven by consensus, which ensures 86

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that the members of a given PPP have a stake in the issue and the PPP’s success (Reich 2002). Their voluntary nature lends itself to creating arrangements that are explicitly results-oriented with defined objectives and roles for the members (Harman 2012: 76). They also tend to try and apply the logic and development strategies common in private business in venues that involve governmental entities (Grimsey and Smith 2004). In essence, they argue that they can apply the logic of the private sector to problems in the public sector to overcome governance and market failures. The popularity of PPPs does not insulate them from criticism. Hodges and Greve argue that the actual efficacy of PPPs with regard to service provision is mixed at best. They also question how well PPPs define the roles for the various members of the partnership. While PPPs may talk about their ability to clearly define each member’s place within the organization, practice suggests this process is far less clear than commonly assumed (Hodges and Greve 2007). Buse and Harmer question how much partnership actually exists within PPPs, particularly when the relationship involves parties from the Global North and the Global South. PPPs emerge with an aura of legitimacy and power, but they tend to constrain critical analyses of their operations and reinforce existing power relationships. This calls into question the transformative abilities of PPPs (Buse and Harmer 2004). Hodge further finds that governmental bodies are less well equipped than private actors to deal with the risks that can emerge from PPPs, potentially exposing governments to significant liabilities if problems emerge (Hodges 2004). Even with these limitations and questions about the performance of PPPs, this new form of global health actor has demonstrated an ability to draw in a wider range of actors than had previously been involved in this space. It has also increased the level of financial resources available for global health. As such, they have contributed to the creation and expansion of global health governance within international society.

Non-State and Private Actors Traditionally, governance within the international sphere has come from states. Individual governments provide leadership on a given issue, or states cooperate through formal international organizations or international regimes. International actions derive their legitimacy and authority through their connection to sovereign-state governments. In recent years, though, nonstate actors have played an increasingly important role. NGOs have produced authoritative reports on human rights abuses, multinational corporations have worked to create standards of conduct, and citizen movements have pressured repressive governments to step down. The presence of these non-state 87

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actors within the realm of international governance has complicated lines of authority. States increasingly share power and authority in the international arena with a wide variety of non-state actors. This seemingly innocuous shift in international relations has profound implications. International action has long been considered the sole domain of sovereign states, yet we witness a shift whereby non-state actors fulfil the roles and functions traditionally accorded to states. Private actors—be they individuals, philanthropic organizations, or private businesses—are being accorded the ability to engage in international relations as legitimate actors in certain realms (Hall and Biersteker 2002). Whether this shift is the malevolent manifestation of private actors usurping state power for their own ends (Pauly 1997; Strange 1996) or is symptomatic of the need for broad-based solutions to increasingly complex global problems and the inability of states to adequately address them on their own (Schwab 1997; Webb 2004), the fact remains that private and non-state actors are becoming significant actors in the realm of global health governance. Not only do they have money, but they can also help set the research agenda and sit on the boards of various international global health-related organizations. Private and non-state actors encompass a wide range of organizations and legal entities. Within this broad category, three types of private actors are typically prominent within global health governance: NGOs like South Africa’s Treatment Action Campaign and Médecins Sans Frontières (MSF)/Doctors Without Borders; prominent individuals like Bono and Jeffrey Sachs; and philanthropic organizations like the BMGF and the Rockefeller Foundation (RF). What sets these different types of private actors apart from other global health actors is that they have, through a variety of means, acquired some measure of power and legitimacy within global health governance. This is not to say that they should have this legitimacy, and the lack of public oversight over their activities and influence has the potential to raise troubling questions, but the contemporary global health governance architecture is inexplicable without making reference to the operations of private actors.

Non-Governmental Organizations International organizations of all different varieties have promoted the benefits and necessity of collaborating with NGOs. These groups occupy a ‘third place’ between the government and the market, ostensibly possessing a sense of independence that allows them to craft interventions that better respond to local needs. While these sorts of groups have long existed, the term non-governmental organization itself only goes back to the founding of the United Nations. The Charter of the UN’s Economic and Social Council 88

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(ECOSOC) empowers the body to consult ‘with non-governmental organizations which are concerned with matters within its competence’. ECOSOC then defined an NGO as any organization not established by intergovernmental agreement and not a profit-making private business (Davies 2014: 3). NGOs can play a role in global health governance in a number of different ways. First, they may act as direct service providers in the absence of state-run services. Knijn and Slabbert describe how international NGOs have provided a substantial portion of HIV/AIDS-related health care services in rural parts of South Africa (Knijn and Slabbert 2012). Downie describes how, even before the Ebola outbreak began in 2014, NGOs provided the bulk of health care services in Liberia. The country’s fourteen-year civil war left the government without the resources or personnel for the population’s health needs, so NGOs and faith-based organizations filled the void in an effort to at least provide basic health services (Downie 2012). Seckinelgin notes that, while NGOs have played an important role in direct service provision, they generally lack the resources and agency to address the long-term policy interventions that will transform global health governance (Seckinelgin 2005). Second, NGOs can direct international disease control and eradication campaigns. Their ability to work in multiple locations, along with their seeming impartiality, may give them opportunities that government-based actors may lack. The Carter Center, for example, has led the international campaign to eradicate Guinea worm. In 1989, there were approximately 900,000 cases of Guinea worm infection in twenty different countries. By 2016, that number was down to twenty-five in only four countries (Carter Center 2017). Rotary International initiated its PolioPlus programme in 1985 to jumpstart the global polio eradication campaign, and it remains a crucial element in the Global Polio Eradication Initiative today (Aylward and Tangermann 2011). Even more strikingly, vaccination campaigns by NGOs and international organizations have managed to broker temporary ‘vaccination ceasefires’ in the midst of ongoing conflicts (Hoetz 2001). Third, NGOs can act as important partners with government-based organizations. NGOs may possess a degree of flexibility and adaptability that states and international organizations lack, giving them certain comparative advantages in reaching out to affected communities. Jonathan Mann recognized the value of NGOs while he directed the Global Programme on AIDS in the late 1980s and early 1990s. Because of the discrimination and stigma faced by many HIV-positive persons, they were reluctant to engage with the state to receive services. NGOs offered an opportunity to make connections with marginalized communities. Both state-based actors and NGOs had the same goal—to provide services to HIV-positive persons—but NGOs could leverage their comparative advantages to increase the range of groups they could reach (Lisk 2010: 18–19). This increasing emphasis on partnerships between NGOs 89

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and other actors has led to a tremendous rise in the number of health-related NGOs. It has also called into question how independent NGOs truly are, leading to concerns about the emergence of an ‘NGO-industrial complex’ in global health (Adams 2013: 77). Finally, NGOs can operate to bring greater international attention to global health issues and put pressure on governments and international organizations to take more aggressive actions to deal with the concern. Davies attributes much of the impetus behind the Doha Round of negotiations on intellectual property rights and generic pharmaceuticals to the efforts of MSF and its allies shaming the US and European governments for refusing to allow generic pharmaceutical manufacturers to produce HIV and tuberculosis drugs for sale and distribution in low-income states (Davies 2010: 50). NGOs have also pressured governments to improve their infectious disease surveillance capabilities. Under the terms of the IHR (2005), WHO can act on reports of infectious disease outbreaks from non-state sources. This change was made to put pressure on governments to increase their own surveillance capabilities by decreasing the likelihood a government could hide an outbreak (Davies and Youde 2015b: 9–12).

Prominent Individuals International relations theory typically shies away from focusing too much on first image or individual-level analysis. As Waltz argues, an individual’s activities may explain a discrete event, but they cannot explain the existence and persistence of broader patterns of international behaviour (Waltz 1959: 42–79). Despite this reluctance, the experience of global health governance suggests that individuals can and do have transformative effects that have helped to fundamentally reorder how the international community conceptualizes and responds to transnational health concerns. Jonathan Mann, the director of the Global Programme on AIDS when that programme operated entirely under WHO’s aegis, is personally credited with injecting international AIDS programming with a strong focus on respecting human rights (Altman 1999: 568). His personal lobbying efforts also receive substantial credit for convincing developed states to provide financial assistance for HIV/AIDS efforts in developing countries (Gordenker et al. 1995: 74). Busby argues that Bono, lead singer of the Irish rock band U2, played a determinative role in shifting US policy on international AIDS funding. Bono was able to use his Christian faith to connect with Jesse Helms, the conservative Republican senator who was then the head of the powerful Senate Foreign Relations Committee and a staunch opponent of HIV/AIDS programmes. Through their shared religiosity, Bono helped Helms to recognize the United States’ obligation to assist those in other countries, which helped set the stage for the 90

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US government to become a major global health donor (Busby 2007). Jeffrey Sachs, the ‘rock-star economist’ who was a special advisor to UN SecretaryGeneral Ban Ki-moon on the Sustainable Development Goals, used his highprofile positions and academic training to encourage the international community to commit to specific targets for improving health and alleviating poverty. While the success of Sachs’ various initiatives is debatable (Easterly 2006; Henwood 2006), his influence in shifting the tone and rhetoric of the international discussions around global health aid is undeniable. In general, these celebrities are individuals who have achieved a degree of fame or stature in one area who then leverage their public status to call attention to global health issues. Bill Gates rose to prominence through his work founding and leading Microsoft before turning his attention to global health. Jimmy Carter and Bill Clinton both served as presidents of the United States, but global health did not figure prominently during either man’s tenure. In their post-presidential lives, though, both created foundations that have made global health one of their central issue-areas. Jeffrey Sachs was an academic and policy advisor who had been previously best known for his (much-criticized) work on the economic transitions of post-communist states. What sets these individuals apart, though, is their ability to translate their fame in realms outside of health and public policy into having an effect on the global health politics agenda. There is no obvious connection, for example, for Bono between being the lead singer for one of the world’s bestselling rock bands and campaigning for increased funding and treatment options for HIV-positive persons. Cooper argues, though, that celebrities and prominent individuals can harness their stature to bring a sense of optimism and raise public consciousness to a wide variety of issues (Cooper 2007). In this way, they generate public attention and policy pressure beyond what generally happens through other avenues of political action.

Philanthropic Organizations Philanthropic organizations engaged in global health exist primarily to distribute funds to other groups, organizations, or entities. As opposed to other types of charitable organizations, philanthropies derive their resources from wealthy individuals or corporations instead of soliciting donations from the general public. The philanthropy or foundation will also usually have a defined set of purposes or issues for which it will give money (Williams and Rushton 2011: 3). While it may be tempting to describe philanthropic foundations as new global health actors, it would be more accurate to describe them as re-emergent actors. As described in Chapter 3, the RF’s International Health Division was a major player in addressing international health concerns between 1913 and 1951. Until the 1940s, the RF spent more on international aid than state 91

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governments did (Moran 2011). Indeed, the League of Nations Health Office relied crucially on support from the RF to sustain its operations (Farley 2004). While the emergence of WHO and other health-related intergovernmental organizations may have displaced philanthropic organizations in the realm of health aid, foundations have re-emerged as prominent global health actors since the 1980s. One analysis found that development assistance for health (DAH) from private sources rose from 19 per cent of the global total in 1988 to 26.7 per cent in 2007 (Ravishankar et al. 2009). This funding comes from a variety of philanthropic foundations, like the BMGF, the Clinton Foundation, the RF, the Bloomberg Philanthropies, and the Wellcome Trust. Philanthropic foundations argue that they have unique qualities that allow them to operate effectively in addressing global health. The RF initially positioned itself as being able to bring the power of science to bear on health issues so as to benefit economic development worldwide (Waitzkin 2011: 3). The Clinton Foundation leverages the unique stature of Bill Clinton for facilitating agreements between states and private industry for mutual benefit (Youde 2011a: 165–7). Bill Gates argues that his foundation, the world’s wealthiest philanthropic foundation, can apply the business insights, technical knowhow, and focused intensity that allowed Microsoft to prosper in the realm of global health (Youde 2012: 85). In essence, because philanthropic foundations are not beholden to outside interests, they argue that they can operate more nimbly and adjust rapidly to changing circumstances in ways that state-based organizations cannot. Further, they also posit that they can provide funding for global health priorities that states are unable or unwilling to fund, such as research and development for neglected diseases (McCoy and McGoey 2011: 143–4). Rather than replacing governments, philanthropic foundations generally see themselves as correcting political or market failures and filling in gaps. Critics allege that the activities of philanthropic organizations often obscure their more malevolent effects. First, they argue that philanthropic organizations ignore their conflicts of interest because their funding comes from the very activities that give rise to health problems in the first place. BMGF, for example, has come under criticism for investing in oil and food companies whose business interests cause the pollution and malnutrition that damage lives (Piller et al. 2007). Second, they charge that philanthropic foundations reinforce the very systems that gave rise to global health disparities in the first place. Foundations get their wealth from individuals and corporations who have exploited the nature of neoliberal economic policies to enrich themselves and harm the vast majority of the world’s population. Instead of challenging the basic tenets of the international economic system and how it allows people to suffer, these philanthropies profit from it and reinforce the disparities. Hindmarsh writes, ‘To overcome widespread disaffection with the new order’s 92

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gross inequalities and labour relations, and to strengthen the institutions of capitalism, elite managerial ideals combined with corporate philanthropy’ (Hindmarsh 2003: 12). Third, philanthropic organizations use their wealth to shut down opposing opinions or crowd out other voices. BMGF has invested a great deal of money in malaria eradication efforts by funding vaccine development. Because it is so financially dominant in this field, critics allege that the Gates Foundation cowers its doubters into silence; the only way to get money for malaria research is by adhering to BMGF’s line (Cueto 2013: 48–50). Finally, philanthropic organizations lack accountability and have only a tenuous grasp on any claim to being a legitimate international political actor. There is no ability to place a check on what philanthropic organizations do, effectively severing ties between health interventions and the people affected by them. As such, philanthropic organizations essentially base their legitimacy on their wealth rather than through any sort of positive affirmation or renewal from the populace, but Harman argues wealth cannot manufacture legitimacy (Harman 2016). As with the other non-state actors described above, these various private actors have increased the number and range of those actively engaged with global health governance. They have also increased the financial resources available for global health. At the same time, international society is still trying to figure out how best to incorporate these new actors into existing structures.

Conclusion Global health governance is a multifaceted amalgamation of institutions and organizations operating at different levels to create a secondary institution within international society and related to the primary institution of moral responsibility. It is a system that technically lacks hierarchy or explicit order, making it relatively easy for a wide variety of different types of actors to get involved in a variety of ways. These various elements may share the same goal—addressing transnational health concerns—and they may rely on the largesse of various elements of the international community in order to fund their operations, but they may not necessarily coordinate with one another. It is only through an understanding of the various elements of global health governance—intergovernmental organizations, multilateral funding agencies, NGOs, private actors, PPPs, and states—that we can appreciate some of the nuances of global health governance in the contemporary era and how the system evolved into its current state. The global health governance system reflects the emergence of an international society that understands supporting global health behaviourally, financially, and normatively is a constitutive element of what it means to be 93

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a good international citizen. This is seemingly a positive trend within the international community and emblematic of the shifting perception of the sorts of values for which international society stands. The secondary institution of global health governance provides evidence that international society has come together to share common beliefs, ideas, and values around health matters. The global health governance system also highlights the value in expanding the boundaries of international society beyond states. Global health governance, perhaps more so than other transnational governance systems, explicitly incorporates and gives voice to non-state actors who, in turn, have a genuine effect on the system itself. The institutional architecture of global health governance recognizes that states alone cannot tackle the wide range of issues, concerns, services, and finances necessary to support it. These non-state actors contribute to and participate in the process of shaping and being shaped by the various interactions that occur within this system. It is important to remember that the emergence of global health governance as a secondary institution, related to a primary institution of moral obligation and responsibility, within international society does not mean that there is complete agreement on all issues. The institutions that support and facilitate global health governance have not necessarily identified the best techniques for supporting the system. Disagreements over tactics and strategies will exist, but that does not negate the existence of international society itself. The members of this international society will have to continue to work to identify its rules, norms, and expectations. There will be contestation among parties over what constitutes appropriate behaviour. There will be debates over who belongs within this international society. There will be disagreements among the various parties over who is in charge (if anyone) and how this international society should be ordered. Chapters 5, 6, and 7 will discuss how this array of actors in global health governance operate within international society and the challenges it faces. The increase in DAH has been remarkable, but it also raises questions about whether the money is going where it is most needed. The international community largely pulled together to respond to the Ebola outbreak, but many institutions came in for significant criticism for their slowness and lack of urgency. China has emerged as a potential player within global health governance—and one that could have a significant effect on the system as a whole—but there remain ambiguities both about China’s interest in greater involvement and the receptivity of international society to non-Western states. These chapters thus let us explore how international society tries to put global health governance into action and the difficulties that remain with this sort of process.

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5 Development Assistance for Health

In 1983, two years after the first published reports about what we know as AIDS appeared, the World Health Organization (WHO) circulated an internal memo about how the organization should respond to this new disease. Arguing that the disease primarily affected wealthy, Western countries, the memo’s author stated that WHO did not need to involve itself in responding to AIDS because it ‘is being very well taken care of by some of the richest countries in the world’ (cited in Mann et al. 1992: 228). This prediction did not hold. Between 2000 and 2016, global health aid for HIV/AIDS alone totalled more than $116 billion (Institute for Health Metrics and Evaluation 2017: 48). This staggering growth in financing for one single disease is emblematic of the incredible increases of funding for global health governance and how international society has come to see the provision of such funds as vital and a marker of good international citizenship. To understand how global health governance operates as a secondary institution, it is not enough to simply examine the functioning of specific intergovernmental organizations or other actors. Formal organizations are but one part of global health governance’s role within international society. Institutions also include norms, rules, and behavioural expectations for how the actors within international society will act. Therefore, a thorough investigation of global health governance must also look at how the ideas undergirding global health governance manifest themselves. One of the most visible ways to do that is through an examination of official development assistance for health (DAH). This is a case where we can examine the willingness of state and non-state actors to back up their rhetoric with specific, tangible action. If actors are unwilling to support their words with financial commitments, or if they do not reference the underlying norms when justifying their failure to meet these expectations, then that would suggest that global health governance’s place within international society and its emerging norm of moral obligation and responsibility is shallow at best.

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An examination of DAH provides additional benefits. First, because nonstate actors have played substantial roles in providing international funding for global health programmes, it requires us—and, by extension, the English School—to grapple with the place of non-state actors within international society. Second, it draws explicitly on understanding the role of international political economy and foreign aid within international society. Third, the changes in the composition of DAH allow us to trace how global health governance has evolved over the past generation. Fourth, it highlights how the emergence of this secondary institution within international society is not a settled process. Institutions and their normative bases do not emerge fully formed and perfect. They respond and react to their experiences and environments and change. This is just as true for global health governance as for other institutions within the English School. This chapter begins by providing an overview of DAH and its growth since 1990. It then moves on to look at how the areas of emphasis have changed. The third section explicitly examines the role of various types of non-state actors in providing DAH and their increased financial power. The final section discusses the shortcomings that exist within DAH and how they pose challenges for global health governance.

Trends in Development Assistance for Health Global health has received unprecedented attention from the international community over the past generation, and the vast increase in funding is one concrete manifestation of that attention. This proliferation of funding has allowed for the creation of many new programmes, the substantial expansion of others, and the promise that the international community would continue to devote resources towards global health programmes. Though there exists no single methodology for tracking DAH, which leads to varying estimates from different reporting sources, evidence from different sources shows that global health funding has increased—and increased significantly. According to OECD, between 1973 and 2004, DAH experienced an average annual increase of 5.4 per cent. From 1998 to 2002, aid for health shot up 13 per cent per year on average. These increases are all the more remarkable when we consider that overall overseas development aid fell between 1992 and 2000. By 2002–4, aid for health made up 13 per cent of all bilateral official development assistance (Organisation for Economic Cooperation and Development 2013). The World Bank’s accounting found that DAH increased from US$2.5 billion in 1990 to US$13.5 billion just fourteen years later (McCoy et al. 2009). The Council on Foreign Relations calculated that international financial support for global health from both public and private sources shot up from 96

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US$5.6 billion in 1990 to more than US$27 billion in 2010 (Council on Foreign Relations 2013). The Institute for Health Metrics and Evaluation (IHME) has developed a DAH accounting framework that incorporates both public and private funding over time and in constant dollars. In 1990, the first year for which IHME presents data, the international community gave approximately $7.1 billion (in 2016 US dollars) for DAH. The largest portion of those funds—nearly half the total amount—came through bilateral contributions from one country directly to another. Non-state actors, like NGOs and private foundations, provided just over 10 per cent of that total. Fast forward a quarter of a century, and the situation has changed dramatically. In 2016, the international community gave $37.6 billion (in 2016 US dollars) in DAH funds—the second-largest amount ever recorded, and a fivefold increase in the span of twenty-six years. NGOs and private foundations were now responsible for more than $11 billion in funding—just over 30 per cent of total DAH in 2016 (Institute for Health Metrics and Evaluation 2017: 32–3). While DAH was less than 2 per cent of the total official development assistance (ODA) in 1990, it had jumped to 12 per cent of total ODA by 2010 (Institute for Health Metrics and Evaluation 2013: 18). IHME divides these funding changes into three distinct phases. From 1990 to 2001, global health funding underwent a ‘moderate growth’ phase. During this time, DAH increased steadily at an average annualized growth rate of 5.9 per cent. From 2001 to 2010, DAH increased dramatically with an average annualized growth rate of 11.2 per cent. Beginning around 2010, as the effects of the global financial crisis emerged in national budgets, DAH funding entered a period of ‘no growth’ where resources remained relatively stagnant (Institute for Health Metrics and Evaluation 2013: 10). The relative stasis in funding has seemingly become the ‘new normal’ for DAH (Institute for Health Metrics and Evaluation 2017: 22). With the emergence of the global financial crisis in 2008, there was a general anxiety among global health observers that DAH would suffer irreparable harm. The Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) reported a decline in funding from US$8.7 billion in 2009 to US$7.6 billion in 2010 (United Nations 2012). After this decline in funding, the Global Fund underwent significant restructuring, overhauling its accounting and grant administration processes and engaging new leadership. LeachKemon et al. pointed to the dramatic slowdown in DAH, with UN agencies seeing a real decline in these funds between 2010 and 2011 (Leach-Kemon et al. 2012). In 2011, WHO Director-General Margaret Chan announced that the organization was facing a $300 million shortfall in its budget. She attributed the deficit to tight finances among member-states (Faid and Gleicher 2011). As a result, the organization slashed its budget by $1 billion and cut 97

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three hundred jobs at its headquarters in Geneva (Nebahay and Lewis 2011). Soon thereafter, the World Health Assembly, WHO’s annual policymaking meeting for all member-states, passed a biennial budget for 2012–13 that cut the organization’s expenditures by 13 per cent from 2010–11 and was nearly $1 billion less than the Secretariat’s initial proposal of a $4.8 billion budget (World Health Organization 2013). This forced the organization to cut a number of its programmes. A number of traditional donor states, like Canada, Japan, the Netherlands, and Spain, announced or projected that they would need to reduce their bilateral DAH outlays (Institute for Health Metrics and Evaluation 2013: 10). These budgetary changes stoked fears that the good times for global health were coming to an end. In an era of austerity where governments were looking to cut non-essential spending as much as possible, many worried that global health funding would be among the first programmes to go because they were too distant from a country’s strategic or humanitarian interests. The recession’s effects on the United States seemed poised to deliver serious consequences for global health. The US budget for DAH, traditionally the largest in the world in terms of dollar amounts, was threatened by particularly dire cuts. In 2010, the United States gave approximately $10 billion in health aid—the largest amount from any single country and nearly 36 per cent of all ODA for health that year (Institute for Health Metrics and Evaluation 2013: 35–8). The combination of the global economic recession and budget cuts required under the sequestration policy had a large effect on its global health budget. The President’s Emergency Plan for AIDS Relief (PEPFAR), the US signature global HIV/AIDS programme and the largest single global health programme, and its associated programmes saw a budget decrease of 5 to 5.5 per cent, leading to a reduction in the number of people receiving services (Garrett 2013). Cuts to the National Institutes for Health and the National Science Foundation—both of which provide substantial funding for global health research—reduced the overall number of grants awarded and introduced reductions in already existent multiyear grants (Kaiser 2013). Overall, the US government’s spending on all global health programmes decreased in fiscal year 2013 by 4.3 per cent—from $10.05 billion to $9.62 billion (Kaiser Family Foundation 2013). At the time, the major fear was that the cuts to global health funding from the US government could be the proverbial canary in the coal mine. If the US cuts were permanent, it could signal a dramatic shift and depress DAH more broadly. That could signal a normative shift within international society that DAH was actually more of a luxury than a core element and not in its long-term interests. Surprising many observers, though, the pessimistic predictions have not come to pass. The decreases that initially emerged as the recession began were largely temporary in nature and may have been reflections more of domestic political debates than symptomatic of larger changes within the international 98

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community. As IHME explains, ‘Overall, while many OECD countries are still grappling with stunted economic growth, health assistance has not radically contracted, emphasising the high priority numerous global health stakeholders place on global health’ (Institute for Health Metrics and Evaluation 2014: 10). While total global DAH declined between 2011 and 2012, it rebounded in 2013 to $38 billion (in 2016 US dollars) (Institute for Health Metrics and Evaluation 2017: 95)—the highest level on record, ‘despite the lingering effects of the global financial crisis and the austerity measures implemented across the Organisation for Economic Cooperation and Development countries’ (Institute for Health Metrics and Evaluation 2014: 15). Between 2010 and 2016, DAH has consistently hovered around $36 to $37 billion (in 2016 US dollars) with relatively small annual fluctuations. This consistency signals a continued commitment by the international community to funding global health. While the overall spending for global health may be plateauing, DAH in 2015 accounted for more than 25 per cent of all official development assistance. Between 2000 and 2010, DAH increased 2.6 times faster than the global economy as a whole and 2.9 times faster than official development assistance (Institute for Health Metrics and Evaluation 2016: 13). Even with DAH reaching a plateau over the past five years, ‘important development partners signalled they remained steadfast in their commitment to global health financing’ (Institute for Health Metrics and Evaluation 2016: 9). For the most part, DAH levels recovered quickly and matched or exceeded earlier high funding levels—even as total spending for foreign aid stayed constant or decreased. While the rate of increase in global health funding has slowed considerably, and there are substantial questions about the future implications of relatively static global health spending, the fact remains that international society has prioritized global health spending to a degree unanticipated by most observers. Global health spending is subject to larger structural constraints that exist within the international community, but the continued interest in funding global health demonstrates the increasingly foundational position that global health funding occupies within international society and as part of a larger cross-national institution in support of moral obligation to assist other peoples and states. Longer-term studies give us reason to be cautiously optimistic about global health aid’s place within international society. Research suggests that global health aid is generally resilient in the face of economic hardships. Stuckler et al. examined health aid spending by fifteen OECD countries between 1975 and 2007, looking to see whether governments gave less for health during recessions and in their aftermath. They discovered no statistically significant association between recessions and DAH commitments or disbursements (Stuckler et al. 2011). The maintenance of global health funding even in the face of economic downturns suggests ‘the importance of other global health 99

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debates and to political factors in determining aid allocations’ (Stuckler et al. 2011: 254–5). Governments have, to a certain degree, embraced a shared interest and value in maintaining an active response to addressing global health needs.

Where Does Global Health Aid Go? The mere fact that international society has created a sort of norm and behavioural expectation around providing financial assistance to address global health issues does not mean that said funds are allocated equally or ideally. Funding is not necessarily correlated with mortality and morbidity rates, and its connection to the global burden of disease is tenuous at best. On the one hand, this is not necessarily a bad thing; the amount of funding required to address something like HIV/AIDS is not the same as the amount of funding needed to provide a vaccination against polio. Raw funding levels do not tell us about the degree of severity of a disease or the costs associated with treating it. On the other hand, there exist tensions over why certain health matters receive seemingly outsized attention and resources. This raises questions about which issues within global health are prioritized and how the structures of global health governance may privilege certain concerns. Global health programmes can generally be categorized as either horizontal or vertical, and the differences between these two categories says much about the competing approaches to delivering health services. Vertical programmes are disease-specific, and they often operate separately from the broader health services delivery systems in a country. The Stop TB Partnership, an international partnership aiming to improve access to tuberculosis medicines and reduce transmission, is an example of a vertical programme. By contrast, horizontal programmes focus on broad-based interventions that strengthen the health care infrastructure as a whole and address the wide range of health conditions that a person may present (Oliveira-Cruz et al. 2003: 68). The Health for All by 2000 movement and its commitment to comprehensive primary health care is a horizontal programme. Though horizontal programmes are generally seen as having broader effects on improving a population’s overall health, vertical programmes receive the bulk of DAH funding. In 2016, health systems strengthening (HSS), which is a horizontal intervention because it is focused on generalized support to the health care system, received less than 10 per cent of all global health aid. While this is still a relatively low percentage of total funding, it has increased in year-over-year levels. That may be the result, in part, of the Ebola outbreak laying bare the potentially calamitous effects of weak health systems (Institute for Health Metrics and Evaluation 2017: 64–7).

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Donors may find vertical programmes more attractive for funding because they can be quantified more easily and lend themselves to discrete interventions for which donors can take credit. That does not eliminate questions about their overall efficacy, though. DeMaeseneer et al. (2008) argue that, despite the high levels of funding they receive, vertical programmes do a poor job of increasing access to health services for those most in need. They also point to the diversion of resources away from the general health services, arguing that vertical programmes undermine the larger public health infrastructure. Magnussen et al. (2004) find that vertical programmes cannot adequately address the underlying social determinants that give rise to ill health. Garrett (2007) says that vertical programmes reflect the interests of donors rather than the recipients, distorting the global health agenda. Others find that the effectiveness of vertical programmes is fairly limited unless those interventions also invest in more horizontal measures (Bärnighausen et al. 2011). While Ooms et al. (2008) caution against drawing too great a distinction between horizontal and vertical programmes and suggest that both have a role to play, it is impossible to ignore how the different delivery modes have had a distinct effect on funding decisions and the global health political agenda. When looking at how DAH funds are allocated, disease burden in and of itself fails to explain the distribution. Mortality and morbidity arguments do not explain the relative amount of money different issues on the global health agenda receive. Nearly 30 per cent of all DAH goes towards HIV/AIDS programmes—a disease that killed 1.2 million people in 2014. Tuberculosis receives approximately one-tenth that amount, even though it is the leading cause of death among infectious diseases. Non-communicable diseases (NCDs) received less than $650 million in 2016, even though they are responsible for 68 per cent of all deaths worldwide annually (Institute for Health Metrics and Evaluation 2017: 60; World Health Organization 2014f). Rather than relying on epidemiological statistics to understand global health funding allocations, Shiffman explains these seeming discrepancies by looking at how framing has an effect on funding priorities. He finds that global health issues receive more funding when their advocates frame the issue in a manner that resonates with policymakers. They position the issue in a way that attracts support from governments and institutions that is not necessarily related to the actual level of death or disability associated with the condition (Shiffman 2009: 608–13). The vast disparity in funding for NCDs as compared to infectious diseases makes sense from this framework. If NCDs are framed as resulting from individual lifestyle choices as opposed to reflecting the influence of large corporations and creeping neoliberalism within the international community (Glasgow and Schrecker 2015), then they are unlikely to receive the sort of funding and attention that goes towards a disease like HIV/AIDS,

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which is framed as an issue of development, human rights, poverty, humanitarianism, and international security (Shiffman 2009: 609). In terms of geographic distribution of DAH, sub-Saharan Africa has received more money than any other region throughout the past generation. In 1990, sub-Saharan African states received $1.54 billion in aid. That amount worked out to nearly 22 per cent of global health aid. In 2016, the region received nearly $14 billion (in 2015 US dollars), or 38.8 per cent of all global health aid (Institute for Health Metrics and Evaluation 2017: 96–7). While sub-Saharan Africa has consistently received the largest portion of geographically specific aid, largely due to HIV/AIDS-related funding, there has been more volatility among other regions. Southeast Asia/East Asia/Oceania ranked second in geographically specific health aid in 1990, followed by South Asia, and Latin America and the Caribbean. By 2013, though, cross-regional programmes had become the second largest recipient of geographically specific health aid, followed by South Asia, Southeast Asia/East Asia/Oceania, and Latin America and the Caribbean. It is also worth noting that the largest portion of global health aid is not geographically targeted. Among specific health issues, spending priorities changed dramatically between 1990 and 2013. In 1990, the largest allocation for any single health concern went to maternal health. That year, maternal health programmes received almost $1.6 billion (in 2016 US dollars), which was 22.5 per cent of total global health aid. Newborn and child health came in second with $914 million, while support for health sectors in general received $543 million. HIV/AIDS, tuberculosis, and malaria combined received less than $415 million (Institute for Health Metrics and Evaluation 2017: 106–7). As will be clear in the sections below, global health funding priorities have shifted to a significant degree since 1990.

HIV/AIDS The biggest shift in spending on specific health issues has come from HIV/AIDS, as evidenced by tracking trends using constant 2016 US dollars. From 1993 to 1994, allocations for HIV/AIDS increased dramatically, rising from less than $410 million to more than $725 million in a single year. Even with this impressive increase in spending on HIV/AIDS, it only represented 8 per cent of total global health aid and was well short of the spending on maternal health, newborn and child health, and health sector support. The situation began to change in 2002, when HIV/AIDS spending first exceeded general health sector support ($2.14 billion for HIV/AIDS versus $1.51 billion for health sector support). HIV/AIDS allocations outpaced those for maternal health for the first time in 2002, too. By 2003, HIV/AIDS outstripped all other specific health issues in the amount of global health aid that it received. Not only has HIV/AIDS’ sheer 102

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dollar amount increased over time, reaching a height of nearly $10.5 billion in 2011, but its percentage of overall global health aid has also increased. In 1990, HIV/AIDS received 4.4 per cent of all funding. In 2003, the first year that HIV/ AIDS received the largest amount of health issue-specific funding, it only accounted for 17.9 per cent of global health aid. In 2011, HIV/AIDS received nearly 30 per cent. By contrast, maternal health went from 22 per cent of global health aid in 1990 to less 10 per cent in 2011. By 2016, HIV/AIDS still captured more than a quarter of all global health aid while maternal health made up just more than 10 per cent (Institute for Health Metrics and Evaluation 2017: 106–7). The growth in spending for HIV/AIDS is in line with how the international community’s response to the disease has evolved over time. Leon (2011) describes three distinct phases for the UN’s AIDS apparatus since 1986. In the first phase, between 1986 and 1994, the Global Programme on AIDS (GPA) oversaw efforts to develop and fund AIDS prevention programmes in the Global South. This programme was housed entirely within WHO, where it became subject to fierce contestation over whether AIDS was better conceptualized as a biomedical issue or a reflection of underlying social and political structural faults. These internecine fights took their toll on HIV/AIDS funding from the international community. Donor states reduced their contributions to GPA and redirected their funds towards their own bilateral efforts or towards other UN agencies that had set up their own HIV/AIDS programming (Behrman 2004: 166–7). The second phase started in 1994 and lasted for approximately a decade. Its emergence came about with the creation of a new organization to oversee the UN’s HIV/AIDS programming. The Joint United Nations Program on HIV/AIDS (UNAIDS) deliberately removed the disease from the sole purview of WHO and created a new standalone agency to combine resources from various UN agencies in a coherent manner. To do this, UNAIDS aggressively sought to mobilize funds from donor states in order to scale-up the global response to the disease. This phase saw a massive increase in funding as donor states responded positively to this new organization and operational framework. The third phase, which started in the mid to late 2000s, still features a prominent role for UNAIDS, but the focus areas have shifted. The large annual increases in donor funding are no longer as prominent. Instead, UNAIDS has prioritized a greater emphasis on country-level work, reducing bureaucratic duplications, and increasing efficiency. Instead of getting new money, the idea is to make sure that the funds that are designated for HIV/AIDS are spent in a smart and efficient manner (Leon 2011: 472). The international community’s successes in addressing HIV/AIDS are substantial. In 2014, 36.9 million people were HIV-positive, with 2 million new infections and 1.2 million deaths. Since 2000, new HIV infections have decreased 35 per cent. In 2005, the number of AIDS-related deaths peaked at 2 million. Since that time, AIDS-related deaths have plunged 42 per cent 103

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(UNAIDS 2015b). Between 2010 and 2014 alone, access to antiretroviral drugs has gone up 84 per cent. There are more people living with HIV today because antiretroviral drug access allows HIV-positive persons to live longer, healthier lives. Prevention programmes have prevented 7.8 million new infections (UNAIDS 2015a). In nearly every region of the world, the number of new infections and AIDS-related deaths has dropped. This has been particularly true in sub-Saharan Africa, which is home to the largest percentage of HIV/AIDS cases worldwide. The region has seen the number of new infections decline by 41 per cent and deaths by 34 per cent between 2000 and 2014 (UNAIDS 2015a: 8, 10). While HIV/AIDS funding has significantly increased since 1994 and captures a large proportion of overall DAH, the levels are not necessarily keeping pace with the need. In 2004, UNAIDS estimated that low- and middle-income countries would require $12 billion in AIDS interventions by 2005 and $20 billion in such funding by 2007 (Barnett and Whiteside 2006: 321–2). IHME’s analysis reinforces this argument. While the increased levels in HIV/AIDS funding are welcome, it notes that ‘the future of growth in HIV/AIDS DAH remains uncertain’. Funding from principal donors like the United States is essentially flat. More problematically, the costs are increasing. Antiretroviral therapy (ART) has helped prolong the lives of many and is far more available to people in developing countries, but it is also expensive. In 2000, ART accounted for just over 2 per cent of HIV/AIDS spending. By 2015, it accounted for more than a quarter of all HIV/AIDS DAH (Institute for Health Metrics and Evaluation 2017: 46). On the one hand, this increase reflects increased access to these drugs—a good outcome and a positive reflection on the successes that global health governance has achieved. On the other hand, providing ART is not a one-time cost. Once a person starts these drugs, they must take them for the rest of their lives. As ARTs extend the life expectancies of HIV-positive persons and more people are living with HIV, it will cost more and more just to maintain ART access at current levels—to say nothing of expanding to include those who do not yet have access to them. Updated treatment guidelines have also recommended that HIV-positive persons start ART even earlier. Instead of waiting until an HIV-positive person’s CD4 cell count drops below 350 cells per cubic millimetre (a typical healthy adult has a CD4 count of 500 to 1200 cells per cubic millimetre), WHO released new advice in 2015 that ART ‘should be initiated in everyone living with HIV at any CD4 cell count’ (World Health Organization 2015b: 12). While this recommendation reflects clinical findings that earlier treatment leads to better health outcomes, it also greatly expands the number of people in need of treatment. Even with the substantial reduction in cost for ART since the mid-1990s, scaling-up treatment access to this degree will require a significant level of additional funding. UNAIDS estimates the gap between current funding 104

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levels for HIV/AIDS and those necessary to ensure 90 per cent access to treatment at $9 billion (UNAIDS 2015a: 5). The shifts in HIV/AIDS DAH remind us that increased funding and the international commitment to maintain some level of resources for addressing HIV/AIDS (and global health in general) is not the same as providing enough funding. More could be done with more resources, and the current funds available fall short, but the inability to reach targets is not the same as a lack of interest from international society. Rather, it exposes a gap between what international society claims and what it does—a gap that, as Vincent argued, must at some point be reconciled.

Malaria DAH for malaria has seen a dramatic increase during the twenty-first century. Between 2000 and 2010, malaria-specific funding grew at an average annual rate of 26.2 per cent. Since 2010, it has seen an average annual growth rate of 0.6 per cent. In fact, malaria has received the greatest percentage gains in DAH funding of all health focus areas between 1990 and 2016 (Institute for Health Metrics and Evaluation 2017: 54–5). In 2016, it reached nearly $2.5 in funding (in 2016 dollars) (Institute for Health Metrics and Evaluation 2017: 106–7). Much of the increase in malaria funding can be attributed to two key international initiatives: the Global Fund and the US President’s Malaria Initiative (PMI) (Institute for Health Metrics and Evaluation 2016: 58–9). PMI began in 2005 and combines the resources of the United States Agency for International Development (USAID) and the Centers for Disease Control and Prevention (CDC) with national malaria control programmes in nearly two dozen malaria-endemic countries to reduce transmission, improve access to treatment, and encourage research on medicines, vector control, and diagnostic tests (United States Agency for International Development 2016). Between 2006 and 2016, PMI received $4.93 billion in funding (President’s Malaria Initiative 2017). The money dedicated to malaria is having a positive effect globally. In 2000, there were an estimated 262 million cases of the disease, resulting in 839,000 deaths. Fifteen years later, thanks to the resources devoted to prevention and treatment efforts, the number of malaria cases around the world dropped to an estimated 214 million causing 438,000 deaths. When taking population growth into account, this means that there has been a 37 per cent decrease in the incidence of malaria. Seventy-five countries have seen their malaria incidence rates decrease by at least 50 per cent, with fifty-seven of those experiencing a decrease of more than 75 per cent (Beauchamp 2016; World Health Organization n.d.). More than two-thirds of the decrease is attributed to one simple prevention technique: the distribution of insecticide-treated 105

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bed nets. Governments and NGOs distributed more than one billion of these bed nets between 2000 and 2015, preventing more than 663 million cases of malaria (Bhatt et al. 2015). This has led to some optimistic speculation that malaria could be completely eradicated by 2040, though this would require a significant increase in funding to $6.4 billion annually by 2020 (Newby et al. 2016)—to say nothing of the likely technical innovations necessary to make such an outcome possible. Caution is in order whenever there are predictions of malaria’s imminent eradication. Similar optimism existed during the middle part of the twentieth century. Between 1958 and 1963, a five-year worldwide malaria eradication campaign was in full swing. The US government alone contributed nearly half a billion dollars to the effort, much of which was devoted to spraying DDT in developing countries to kill the mosquitoes that carry the parasite. By 1963, these efforts had contributed to a significant drop in malaria cases to a historic low of 100 million (Shah 2009: 207–12). When the US government refused to authorize additional funds for malaria eradication after 1963, though, the effort stalled and the number of malaria cases rose. Making things worse, the new cases of malaria were increasingly resistant to chloroquine and primaquine—the most common and previously effective treatments for the disease (Garrett 1994: 50–2). The failure of the malaria eradication effort in the 1950s and 1960s inadvertently made the problem that much worse.

Tuberculosis DAH for tuberculosis ranks third among specific infectious diseases. In 2016, tuberculosis-specific programmes received $1.5 billion (in 2016 US dollars)— its highest level of funding on record. The Global Fund is a key site for receiving and disbursing TB-related funding, with nearly 50 per cent of all DAH for tuberculosis passing through the organization. The United States, the United Kingdom, Germany, France, and the Bill and Melinda Gates Foundation (BMGF) are the most prominent donors for tuberculosis control, prevention, and treatment efforts. The rapidity with which tuberculosis has moved up the global health agenda is remarkable. Between 1990 and 2002, the disease received a pittance of funding; indeed, it was not until 2002 that it even received more than $250 million (in 2016 US dollars). The steep increase in tuberculosis funding at this time is no coincidence, as the Global Fund began its operations in January 2002. Between 2002 and 2004, DAH for TB nearly doubled from $277 million to more than $537 million. By 2008, DAH for TB almost doubled again, crossing the $1 billion mark for the first time. Since then, funding has consistently stayed above $1.15 billion (Institute for Health Metrics and Evaluation 2016: 106–7). 106

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That increase also reflects a fairly dramatic shift in the importance attached to tuberculosis within the global public health realm. By the middle part of the twentieth century, many in the public health field believed that tuberculosis would no longer pose a significant problem. Thanks to the discovery of streptomycin, doctors had an incredibly effective antibiotic that seemed to make the thought of a TB-free age a reality (World Health Organization 2011: 100). Unfortunately, the tubercle bacillus gradually developed a resistance to streptomycin and other anti-TB drugs like para-aminosalicylic acid. As a result, TB treatment became less and less effective over time. The rise of HIV also fostered the resurgence of TB, as the weakened immune systems of HIV-positive persons could not keep latent infections in check. People infected with HIV are twenty to thirty times more likely to see a latent TB infection progress to an active state, and nearly all HIV-positive TB patients who do not receive proper medical treatment will die from the disease (World Health Organization 2016e). As a result, there were 7.5 million new cases of tuberculosis around the world in 1990, leading to 2.5 million deaths (Dolin et al. 1994). This translated to a prevalence rate of nearly 300 cases per 100,000 people (World Health Organization n.d. a). Since 1990, and thanks to the resources dedicated to control, prevention, and treatment efforts, the global health governance system has been able to focus attention on tuberculosis. TB prevalence rates have dropped nearly 50 per cent to roughly 160 cases per 100,000 people, and incidence rates have declined by an average 1.5 per cent per year between 2000 and 2014 (World Health Organization n.d. a). This has allowed the international community to meet the Millennium Development Goal (MDG) of halting and beginning to reverse the incidence of tuberculosis. The fact of progress does not mean, though, that international society’s resource allocation for tuberculosis as part of this secondary institution of global health governance within a broader primary institution of moral responsibility matches the need. The Stop TB Partnership, a public–private partnership (PPP) of more than 1,300 members created in 2001 to provide access to TB treatment for all who need it, argues that the reductions in TB have been far too slow and that the international community needs to ramp up its efforts to effectively address the disease. In its 90-(90)-90 Plan, it calls on the world to reach 90 per cent of all people who need treatment (including 90 per cent of people in key populations) and achieve at least 90 per cent treatment success. Achieving these goals, which the Stop TB Partnership itself recognizes as being ambitious, will require $56 billion to $58 billion for implementing TB programmes over five years and an additional $9 billion over that same timeframe for research and development on treatments (Stop TB Partnership 2015: 101–2). The development of new treatments is of particular importance because of the emergence of multidrug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB). WHO estimates that 107

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5 per cent of TB cases are MDR-TB and that 10 per cent of MDR-TB cases are XDR-TB (World Health Organization 2015d). Treating MDR-TB and XDR-TB is harder, costs significantly more, and takes far longer that standard cases of TB. MDR-TB and XDR-TB also pose a greater risk for spread and infecting others.

Non-Communicable Diseases The global health governance system is overwhelmingly geared towards infectious disease, even though the vast majority of deaths worldwide are due to NCDs like cancer, heart disease, and respiratory conditions. The Council on Foreign Relations has argued that the growth in NCDs represents an emerging global health crisis and one whose effects are largely unappreciated by existing global health governance systems (Daniels et al. 2014). As Maher and Sridhar note, NCDs generally receive only about 3 per cent of total DAH for low- and middle-income countries in any given year, and leading global health donors allocate only 2 per cent of their global health outlays for controlling and treating NCDs (Maher and Sridhar 2012). The data on DAH collected by the IHME bear out the relative low priority afforded to NCDs. Between 2000 and 2016, DAH for NCDs cumulatively equalled $6.1 billion. During that same period, the annual allocation for NCDs ranged between $149.5 million (2004) and $655 million (2015) (Institute for Health Metrics and Evaluation 2017: 106–7). Though the figures are low, it is worth noting that financial support for NCDs did increase at an average rate of 9.5 per cent between 2000 and 2016—a good level, but still lower than the increases for HIV/AIDS, tuberculosis, and malaria during that same period (Institute for Health Metrics and Evaluation 2017: 60). Of particular interest in the financing of NCDs is that NGOs and private philanthropies play a more significant role in this realm than in other parts of the global health agenda. NGOs contributed 41.3 per cent of DAH for NCDs between 2000 and 2015, and private philanthropic organizations (particularly the Bloomberg Philanthropies) provided another 18.2 per cent (Institute for Health Metrics and Evaluation 2016: 66). UN agencies and development banks are also significant sources of funding. What explains the disjuncture between high mortality rates for NCDs and their lack of funding within the global health system? Part of the issue is a lack of coherence around which NCDs should be tackled and how. While NCDs have received greater attention within multilateral forums and were even the subject of a United Nations High-Level Meeting in 2011, there remains a lack of shared understanding around the drivers of the problem and how NCDs relate to other issues of human and economic development (Sridhar et al. 2013). Without a shared understanding and political frame, it is hard to marshal the political support to increase funding. There has also 108

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been a tendency to interpret NCDs as illnesses of individual choices. By this line of thinking, people contract NCDs because of lifestyle decisions they autonomously make about diet, exercise, and smoking. As such, they seemingly do not lend themselves as readily to external interventions or inspire the same level of alarm among donor states as infectious diseases do (Benson and Glasgow 2015). In addition, if the responsibility for NCDs lies in personal choices, then the implication is that individuals can make their own decisions in order to improve their health, which then in turn may lower overall medical expenditures (Tesh 1987: 46–7). While WHO explicitly does not take this position and instead strenuously argues that NCDs are rooted in larger social determinants of health and the global economy (World Health Organization n.d. b), the fact remains that the global health agenda has not yet embraced a framing of NCDs that puts them on the same level as infectious diseases.

Health Systems Strengthening Despite the strong arguments that vertical, disease-specific programmes are less effective than horizontal, broad-based programmes that support the general public health infrastructure, HSS is relatively neglected by DAH funding. In 2016, it received $3.6 billion—an increase of almost 6 per cent from the previous year. This recent increase, though, masks the larger trend of decreasing funding between 2010 and 2016. HSS saw its aid allocation drop an average of 2.3 per cent per year during this time period (Institute for Health Metrics and Evaluation 2017: 66). While funding increased in 2016, it is still approximately $600 million below its peak amount in 2011 (Institute for Health Metrics and Evaluation 2017: 106–7). Three reasons may help explain the seeming disjuncture between the acknowledgement of HSS’s importance in improving global health and the general lack of emphasis on these programmes by funders. First, as was discussed in Chapter 4, state spending on health far outstrips DAH. Governments may be expending their own funding on strengthening their health systems and public health infrastructure, and turning to assistance from donors to cover more specialized programmes that they cannot themselves afford. Major private funders like the BMGF explicitly do not support HSS because they see those sorts of programmes as a state’s ultimate responsibility (Storeng 2014: 686). Second, the international community has not organized around HSS. There are organizations—both state-based and civil society-based—which focus on specific diseases like HIV/AIDS, tuberculosis, and malaria. Supporting the development of public health infrastructure lacks the same sort of public support. Harman points out that, because HSS does not have these sorts of champions, it has not been included in major global health efforts like the MDGs 109

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(Harman 2012: 134). Third, vertical programmes tend to embrace resultsoriented approaches that can provide easily quantifiable measures of their success and outreach. HSS is a more complex, nuanced, and amorphous idea. As a result, it is difficult to create measurable indicators (Harman 2012: 135). Without an easy way to monitor and evaluate the success of HSS programmes, donor states may be less inclined to take a risk on programmes that could either be harder to measure or to explain to legislators. While HSS is not the highest profile issue-area on the global health agenda, it is important to highlight that it has received growing levels of attention since 2005. Hafner and Shiffman identify a number of key reasons for this shift. These include worries about the effects of disease-specific programmes on the larger health system, the recognition of the effects of the ‘brain drain’ of health care workers from the Global South to the Global North, and concerns that disease-specific programmes cannot achieve their desired results without a sufficiently strong public health infrastructure. While they welcome this shift to direct more attention and resources to HSS, they emphasize that this reorientation has not necessarily led to a unified, coherent policy approach to the issue (Hafner and Shiffman 2013).

Non-State Actors and Global Health Aid One of the remarkable changes in global health aid since 1990 is how dramatically the range of involved actors has shifted. Initially, global health aid was almost entirely the province of state and governmental actors. In 1990, nearly 90 per cent of all DAH came from bilateral sources, UN agencies, or regional development banks. Private foundations and NGOs played but a small role. Bilateral funding alone made up nearly half of all global health aid that year (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 got involved in providing such aid. Particularly significant is the growth in private foundations/NGOs and PPPs. Private foundations and NGOs have come to contribute an increasing percentage of global health aid, contributing at least 20 per cent of the world total since 2000. A significant portion of that increase comes from the involvement of the BMGF. Between 1999 and 2014, BMGF provided $21.6 billion in grants through its Global Health programme, making the organization an increasingly important player in global health politics (Institute for Health Metrics and Evaluation 2015: 33). IHME’s accounting shows that NGOs and other US-based private foundations provide significant funding for global health, too. NGOs are responsible for more than 30 per cent of all DAH, providing $11.3 billion in 2016 (Institute for Health Metrics and 110

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Evaluation 2017: 32–4). Private businesses have also become increasingly important sources of DAH, providing $690 million in 2016 alone (Institute for Health Metrics and Evaluation 2017: 95). The BMGF has received the bulk of the attention directed towards non-state actors in global health, which is understandable given the foundation’s overall wealth and commitment to global health. New actors may be coming on the scene, though, and many of them are emerging from foundations created by tech entrepreneurs. The Chan Zuckerberg Initiative (CZI) began in December 2015 by husband and wife 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 per cent of their shares in Facebook 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 CZI (Maloney 2015). While it is too early to know exactly what their funding priorities will be, Chan and Zuckerberg mentioned health as one possible area. In 2014, the couple donated $25 million to the US CDC to support its efforts to combat Ebola in West Africa (Kroll 2014). If the CZI does direct some portion of its funding towards global health, IHME suggests that its contributions could help further alter the global health funding landscape as the BMGF and other private philanthropic organizations have done (Institute for Health Metrics and Evaluation 2016: 19). Sean Parker, the creator of Napster and first president of Facebook, and his wife Alexandra have also decided to direct their philanthropic organization towards global health issues. With a $600 million gift in 2015 to create an endowment, the Parker Foundation has dedicated itself to ambitious goals like eradicating malaria and creating immunotherapies for cancer (Di Mento 2015). PPPs, which aim to bring together private sector and government actors to achieve some sort of collective benefit, were essentially non-existent in global health prior to 2000. With the emergence of groups like the Global Fund and the GAVI Alliance, PPPs have provided a greater portion of global health aid. In 2013, almost 18 per cent of all global health aid came from PPPs (Institute for Health Metrics and Evaluation 2014: 21–2). From 2000 to 2014, GAVI Alliance has provided $9.4 billion towards its mission of increasing access to vaccines around the world. The Global Fund has made more than $30.4 billion available during that same time period (Institute for Health Metrics and Evaluation 2015: 31–3). While the overall amount of DAH has increased steadily since 1990, the composition of who is providing that aid has shifted. As noted above, PPPs, private philanthropies, and NGOs have come to assume a far greater role in providing aid. Indeed, while bilateral DAH (money going from one country to 111

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another country directly) has remained relatively steady, it is the spending coming from PPPs and NGOs that has provided much of the increase in recent years (Institute for Health Metrics and Evaluation 2014: 16). To be clear, state governments continue to provide the majority of DAH, and that is unlikely to change in the near future, but the increasingly important role of non-state actors in providing DAH is undeniable. The expansion of global health aid to encompass PPPs, private philanthropies, and NGOs does not suggest that states are no longer the primary vehicles for providing global health aid. States have not lost their privileged place; rather, they are coming to share the global health aid realm in a positive-sum sort of way. More actors involved with global health mean that international society can address a wider range of issues with a growing diversity of strategies. International society’s obligation to provide some sort of response to transnational health concerns has transcended a mere state-centric framework. This is a process of additionality. What is particularly impressive about these increases in DAH and changes in who provides DAH over the past generation is the consciousness with which the international society of global health donors has approached the topic. Instead of being an afterthought, DAH has assumed a central role as part of the normative expectations of how ‘good’ international citizens act. ‘The maintenance of substantial levels of international funding is a sign of the international development community’s enduring support for global health,’ notes the Institute for Health Metrics and Evaluation (2014: 9). Its report goes on to emphasize: Development assistance is often one of the first items discussed for the budgetary chopping block . . . The enduring provision of DAH during a time of fiscal constraint is testament to the international community’s solid commitment to global health. (Institute for Health Metrics and Evaluation 2014: 13; emphasis added)

The above comments are telling. Even in the face of seemingly economically rational logic to reduce foreign aid, and at a time when donor states are reducing their commitments and outlays in other realms of foreign aid, the secondary institution of global health governance has embraced and internalized a shared normative understanding that at least maintaining, if not increasing, existing levels of DAH is a core principle to which members should adhere.

Conclusion The provision of DAH is one of the most overt manifestations of the emergence of global health governance as a secondary institution within a broader primary institution of moral responsibility within international society. It is a 112

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concrete way in which states can demonstrate their acceptance of the idea that there is a responsibility to provide financial assistance in the furtherance of better health around the world. Donors are matching their rhetoric with behavioural changes. Because funding rates and levels are directly observable, it is therefore possible to track the evolution and embrace of global health governance as a key element of international society over time. It is incumbent upon us to bear in mind, though, that the recognition of global health governance’s role within international society is not the same as international society’s response to global health governance being adequate or sufficient. The financial outlays from donor states and non-state actors have been generous in many ways, but that does not mean that the funding is high enough or addressing the right issues. As detailed throughout the chapter, DAH funds have helped international society make significant progress towards improving global health, but there is much work yet to be done. There remain gaps between horizontal and vertical programmes, as well as chronic underfunding in certain key areas. This disconnect illustrates the spectrum between pluralist and solidarist conceptions of international society. As pluralists would expect, donors remain committed to their own interpretations of how they should contribute their funds to achieve positive global health outcomes. As solidarists would expect, there is an understanding of global health governance that expands beyond narrow self-interest to incorporate issues that seemingly have little direct connection to donor states or agencies. It is the movement along this spectrum that helps us to understand the relative balance between pluralism and solidarism in global health governance. The relative funding stasis for DAH since 2010 may be reflective of a greater shift towards the pluralist end of the spectrum or a sign of international society trying to resolve its understanding of the place of global health governance within its broader operations. A focus on DAH also underscores how the English School theorizing could benefit from expanding its horizons in order to adequately conceptualize the dimensions of international society. First, international political economy is an absolutely vital element to understanding the dynamics of international society. The English School’s general lack of engagement with economics limits its analytical insights. The economy is at the heart of so many of the interactions that occur within international society. An unwillingness to examine those economic interactions needlessly obscures many of the relationship dynamics that undergird international society. Second, global health governance is so much more than states. One cannot explain the growth and evolution without incorporating non-state actors into the mix. The resistance to doing so reflects an unwillingness to see non-state actors as vitally important. Non-state actors do play a role in global health governance—and many other institutions within international society. This does not mean that states 113

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have lost power or that we are moving towards a single universal culture. Nonstate actors play an important role in understanding how institutions like global health governance operate within international society. Chapter 6 looks at a specific case of global health governance in action—the response to the Ebola outbreak in West Africa. The response to Ebola was far from successful, and it has prompted serious calls for major reforms to global health governance. The failings of the response to Ebola and the nature of the proposed reforms, though, tell us much about global health governance’s place within international society and the import given to that secondary institution.

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6 International Society Confronts Ebola

On 26 December 2013, a one-year-old boy named Emile in Meliandou, Guinea, died after having fallen ill with a fever, vomiting, and bloody stool. Experts now believe that Emile was the first person to contract Ebola in the recent West African outbreak. Between Emile’s death and the World Health Organization’s (WHO) declaration that the outbreak was over on 29 March 2016, WHO identified 28,646 cases of Ebola and 11,323 deaths in ten countries connected to this epidemic. Guinea, Liberia, and Sierra Leone bore the brunt of the outbreak; all but thirty-seven cases and fifteen deaths from Ebola happened in those three countries. This most recent Ebola outbreak caused more illness and death than all previous outbreaks combined, challenged the ability of WHO and international society as a whole to respond to a transnational health crisis, and raised questions about the future of global health governance. While WHO declared the Public Health Emergency of International Concern (PHEIC) connected to Ebola over in March 2016, the organization cannot really take a victory lap. Its response to the outbreak continues to come under significant criticism for its slowness, unwieldy structure, and lack of resources. At a special meeting of WHO’s Executive Board in January 2015, DirectorGeneral Margaret Chan declared, ‘The world, including WHO, was too slow to see what was unfolding in front of us’ (Chan 2015). WHO has commenced a wide-ranging review of its policies and procedures, and its member-states have started an intense debate about the future of WHO, the development of better reporting and response structures, and the international community’s sense of obligation to each other when disease outbreaks occur. The Ebola outbreak was one of the biggest health challenges to threaten international society over the past generation. It is a viral disease that moves very fast, kills quickly, and still lacks effective treatments or vaccines. Its virulence, lethality, and cross-border dimensions in this most recent outbreak challenged international society in a unique manner—and the response by that same international society largely failed to live up to its obligations.

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Rather than upholding its collective sense of a moral obligation to respond to crises, the secondary institutions of global health governance too frequently dithered and waited far too long to develop a coherent response. Because of its relative youth as a secondary institution, global health governance is still trying to figure out its standard operating procedures. There are disagreements among members of international society about how various health organizations should act. There is a lack of consensus about the financial resources states should be obligated to provide in these sorts of emergency circumstances. There is continued uncertainty about how global health governance should move through and engage with the rest of international society. Ebola lets us examine the awkward stage that goes along with the emergence of a new secondary institution and what happens when that institution faces major challenges relatively early in its existence. The reform efforts illustrate the ongoing contestation over the exact nature of how international society wants this secondary institution to act and operate. At the same time, the response to the Ebola outbreak, slow though it was, demonstrates how broad global health governance has become within international society. While much of the focus of the response to Ebola has concentrated on WHO, it was clearly not the only institution involved in this process. States, intergovernmental organizations, philanthropic organizations, private businesses, and non-governmental organizations (NGOs) all played key roles in creating and implementing strategies to combat the disease. What’s more, the institutions of global health governance had a constitutive effect on the members of international society. Responding to Ebola was not just about protecting national security or keeping it from spreading further; it was a reflection of how state and non-state actors see themselves and their connections to the larger primary institution of moral obligation and responsibility. Furthermore, both the causes of and responses to Ebola have significant connections to broader issues within international political economy. Economic inequality did not directly cause the outbreak in Guinea, Liberia, and Sierra Leone, but it is impossible to understand the extent to which Ebola spread and took root in these three states without an appreciation of their economic circumstances. Economic dimensions also played a significant role in understanding how actors responded to the Ebola outbreak—both in terms of the immediate costs associated with stopping the spread and the longerterm discussions about building more resilient health systems to prevent an outbreak like this from recurring in the future. This chapter will not provide a definitive exegesis of the Ebola outbreak in West Africa; not only is that beyond the scope of this chapter, but the outbreak’s recency means that it is too soon to provide such an authoritative account. Instead, it will look at how international society responded—and 116

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failed to respond—to the outbreak. Perhaps more importantly, it will look at what the evaluations of that response can tell us about the future trajectories of global health governance as a secondary institution within the broader primary institution of moral obligation and responsibility within international society. The chapter proceeds in four sections. It begins by giving a brief overview of the scale of the Ebola outbreak. The next section then describes the response to the outbreak by intergovernmental organizations, NGOs, national governments, and private actors. The third section discusses the proposals for reforming WHO, and global health governance writ large, in the aftermath of the failure to respond to Ebola. Finally, the fourth section looks at what long-term implications Ebola might have for global health governance and international society as a whole.

Ebola in West Africa Ebola is a difficult disease to contain under the best of circumstances. Its origins remain uncertain; it appears to spread to humans from animals, though the exact animal reservoir for the disease is not definitively known. Prior to the 2014–16 outbreak in West Africa, there had only been about two dozen outbreaks, causing fewer than 2,400 illnesses and 1,600 deaths since the first human cases were recorded in 1976 (Centers for Disease Control and Prevention 2016). The disease inspires fear and mystery, but it remained elusive. Its relative rarity meant that there had been little prior research on developing vaccines, treatments, or cures. Ebola’s highly virulent nature also limited research on it to the few laboratories around the world with the highest possible biosecurity precautions. Even if researchers had developed Ebola treatments, the states most likely to need them were also the least likely to be able to afford such interventions. Ebola spreads person-to-person through contact with blood or other bodily fluids. This is an incredibly important fact about the disease. Its spread is entirely dependent upon direct, intimate contact with the bodily fluids of an infected person who is displaying symptoms. It is not transmitted as easily as a cold or influenza, and it does not spread through casual interactions. Within two to twenty-one days of infection, symptoms like fever, weakness, and muscle pain appear. From there, the infection progresses to vomiting, bleeding, diarrhoea, and eventually multiple organ failure. Health care workers can attempt to manage symptoms as they appear and provide fluids intravenously to prevent the dehydration that ultimately causes death. Previous outbreaks have reached 90 per cent mortality rates, though the outbreaks with such high mortality rates tend to have a very small number of cases (World Health Organization 2016c). 117

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Ebola is particularly insidious because it exploits human compassion. Its virulence is highest at the moments when people need care the most. Because it spreads through contact with bodily fluids, health care workers and family members are particularly at risk of contracting the disease as they try to treat the infected (Beaubien 2014). As such, health systems become overwhelmed as they lose staff either to illness or fear of contracting Ebola. This can also give rise to fear of health clinics in the larger population, as people see their friends or family members enter the clinic and then die there. This relationship between health clinics and Ebola’s spread may make people reluctant to seek medical attention, putting additional family members at risk of infection. In addition, funeral and burial rites frequently involve close contact between the deceased and family members preparing the body—at a time when the body’s virus load is at its highest (Francesconi et al. 2003; Hewlett and Hewlett 2007: 78–9). Thus, the very process of mourning the loss of a friend or family member can lead to new cases of Ebola. Stopping the disease’s spread thus requires communities to change long-standing burial and mourning practices. Ending an outbreak requires isolating infected persons and getting local communities to implement specific disease-control measures to stop the spread of the virus. This can prove particularly difficult for outsiders who come into Ebola-infected areas, as they rarely possess an understanding of local practices or cultural contexts (Dionne 2014). A study by Hewlett and Amola of an outbreak of Ebola in Uganda, though, shows that local practices can often be harnessed effectively to reduce the disease’s spread if and when health care workers engage them (Hewlett and Amola 2003). Integrating these local practices effectively, though, requires both an appreciation of them and the deftness to understand the role that they can play. Aside from a single case of a different strain of the disease in Côte d’Ivoire in 1994 (Fomenty et al. 1999), no known human cases of Ebola appeared in West Africa prior to Emile’s death in December 2013. It took nearly three months before the international community knew about the outbreak, though. The first official report came on 23 March 2014, with the announcement from WHO that it had confirmed forty-nine cases and twenty-nine deaths from the disease in Guinea. Guinean government officials also noted that they had identified three suspected cases of the disease in Conakry—the first time that Ebola had ever been seen in a national capital (World Health Organization 2014a). Retrospective analysis reveals that the epidemic began three months before it was reported to WHO. Meliandou, the Guinean community where Emile died, consists of thirty-one households in the Gueckedou District near the borders with Liberia and Sierra Leone. Emile and other children had reportedly been seen playing in and around a large, hollowed-out tree that was home to a large bat population—a suspected animal vector for Ebola. 118

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Within a few days of Emile’s death, his mother, sister, and grandmother became sick (Vogel 2014). The illness continued to spread to additional family members and caregivers. Relatives who came to Meliandou for Emile’s funeral inadvertently took the virus with them when they returned home and fell ill. As the sickness spread, medical officials first suspected cholera, which spreads rapidly through contaminated food and water and causes severe diarrhoea, or Lassa fever, a viral haemorrhagic fever related to Ebola but spread through airborne means and connected to rats. Finally, on 22 March, the Institut Pasteur in France completed its analysis of the samples it had received and announced that the illness was in fact Ebola. French scientists also reported that the virus was of the Zaire subtype, which is the most lethal variety (World Health Organization 2015e). At this point, and in accordance with the requirements of the International Health Regulations (2005), Guinean officials from the Ministry of Health officially reported the outbreak to WHO. After Guinea’s initial report, more cases quickly appeared. The Liberian Ministry of Health reported to WHO that it had confirmed its first two cases of Ebola one week later (World Health Organization 2014b). By 1 April, Guinea had 122 cases of Ebola and eighty deaths, Liberia had eight cases and two deaths, and Sierra Leone was on alert after the bodies of two people suspected of dying of Ebola in Guinea were brought into the country for burial (World Health Organization 2014c). Sierra Leone reported its first official Ebola cases on 27 May 2014, identifying sixteen cases and five deaths. By that point, there were 308 cases among the three states and 200 deaths. The West African Ebola outbreak is officially the largest ever recorded, causing more than 28,000 cases of the disease and more than 11,000 deaths. Ten different countries reported cases connected to the outbreak, but the overwhelming majority occurred in Guinea, Liberia, and Sierra Leone. Sierra Leone had the highest number of cases, with more than 14,000 cases of the disease. Liberia had the highest number of deaths from Ebola, recording approximately 4,800 (World Health Organization 2016b). Many of the cases that appeared outside the three main countries were health care workers who had contracted Ebola while working in Guinea, Liberia, or Sierra Leone and were subsequently repatriated to their home countries for medical treatment. The first case in the United States came for a man, Thomas Eric Duncan, who fell ill after travelling from Liberia to Texas in September 2014. Duncan became the first person to die of Ebola in the United States on 8 October 2014. Two nurses who treated Duncan subsequently contracted the virus, though both recovered. The other cases that appeared in the United States were among health care personnel who had been working in West Africa to treat Ebola patients (Tavernise et al. 2014). Mali experienced eight cases of Ebola. The cases were traced back to a two-year-old girl and a traditional healer in his fifties, both of whom travelled to Mali from Guinea (BBC 2014a). 119

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Nigeria had twenty cases and eight deaths. The virus first appeared there when businessman Patrick Sawyer flew to Lagos from Monrovia and collapsed at the airport. When Sawyer fell ill and later died, public health officials feared that the disease would take root in the large city and make containment and treatment operations nearly impossible. Despite these fears, Nigerian officials quickly ramped up their emergency response operations and instituted comprehensive contact tracing and public educational campaigns that prevented widespread and sustained transmission (Ogunsola 2015).

International Society Responds to Ebola The response to the Ebola outbreak involved nearly all elements of global health governance—states, intergovernmental organizations, and non-state actors. WHO has a constitutional mandate to act as the main coordinating entity for a global response to an international health emergency like an Ebola outbreak, but the diligence and timeliness with which it responded to Ebola left many questions about its ability to lead and whether the international community had provided WHO with the resources necessary to implement an effective response. NGOs picked up the slack in some instances, but they face their own resource constraints and do not necessarily possess the same degree of international legitimacy. Donor states got involved in responding to Ebola by providing money and personnel, but those efforts (especially those that involved the military) raised eyebrows. Coordination among all of these actors did not necessarily happen in an optimal fashion. That said, it is remarkable that even these shortcomings did not raise significant doubts about the role of global health governance within international society. Members want to improve it for next time and have started to embrace the responsibilities attached to global health governance as having a constitutive element to them. After WHO received the first confirmed reports of Ebola in Guinea, it encouraged the international community not to panic. In one of its first press conferences on Ebola on 1 April 2014, Gregory Hartl, a WHO spokesperson, emphasized that the outbreak was ‘geographically limited’ and neither worrisome nor an epidemic. This was in distinction to NGOs like Médecins Sans Frontières (MSF) that had called the outbreak ‘unprecedented’ and warned that ‘we are facing an epidemic of a magnitude never before seen’ (BBC 2014c). Within a week, WHO’s message had changed, and officials described it as ‘one of the most challenging Ebola outbreaks we have ever seen’ (World Health Organization 2015c). This rapidly changing assessment by WHO officials in many ways is emblematic of the response to the outbreak as a whole—initial underestimates followed by changes in perception and quick efforts to scale-up the response appropriately. 120

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In WHO’s own narrative about its responses to the outbreak, the organization’s response was rapid and took advantage of the resources it had available to it—deploying personnel to Guinea (and later Liberia and Sierra Leone), meeting with regional stakeholders, and drawing on the organization’s expertise and knowledge reserves. When groups like MSF called for WHO to take a more assertive response to the outbreak during a meeting on 27 June 2014, Director-General Chan ‘immediately took personal responsibility for the WHO response’ and made plans to hold a high-level meeting with key stakeholders (World Health Organization 2015c). Indeed, WHO did perform these actions—but not necessarily with the speed WHO claimed. It convened an emergency meeting of regional health ministers in Accra, Ghana, on 2 and 3 July 2014 to strengthen surveillance operations and facilitate cross-border consultations (World Health Organization Regional Office for Africa 2014). WHO also opened a Sub-Regional Outbreak Coordinating Centre in Conakry, Guinea, to oversee and coordinate actions (World Health Organization 2014d). The problem is not with these meetings or actions themselves; it is the delay with which they occurred. The meeting in Accra brought health ministers and other senior officials from West Africa together— but that was more than three months after the first report of the disease. The Sub-Regional Outbreak Coordination Centre did not open until 25 July 2014, four months after WHO announced the outbreak. Given how quickly Ebola spreads and its virulence, such delays helped the disease gain a foothold in the region. WHO also received significant criticism for its delays in mobilizing the international community. Under the International Health Regulations (2005), WHO has the authority to declare a PHEIC when a disease outbreak represents an ‘extraordinary event which . . . constitute[s] a public health risk to other States through the international spread of disease and . . . potentially require[s] a coordinated international response’ (World Health Organization 2008: 9). Because Ebola is a disease that has previously demonstrated an ability to cause national or international health concerns, has a serious impact, is unusual or unexpected (particularly in West Africa), has demonstrated its ability to spread across borders, and raises a significant risk for trade and travel restrictions, it would qualify as a PHEIC (Youde 2012: 86–8). Indeed, Ebola’s virulence is so well known that the IHR (2005) specifically name it as automatically triggering the treaty’s decision-making algorithm for reporting outbreaks. A PHEIC declaration mobilizes a coordinated international response, drawing on a wide array of resources. It signals that the international community is making this outbreak a top priority because it poses an extraordinary risk that necessitates large-scale cooperation. Indeed, the International Health Regulations underwent extensive revisions in the late 1990s and early 2000s 121

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specifically to give WHO the power to declare PHEICs to mobilize international support and response to outbreaks like Ebola (Davies et al. 2015: 60–3). Declaring a PHEIC is akin to WHO deploying ‘an international SOS’ (CBS News 2015). Despite the clear match between the characteristics of the Ebola outbreak and the necessary conditions for declaring a PHEIC, WHO’s International Health Regulations Emergency Committee did not make the declaration until 8 August 2014—more than four months after the outbreak began (World Health Organization 2014e). When the IHR Emergency Committee declared Ebola a PHEIC, it did not recommend travel or trade restrictions, nor did it call for international assistance to assist in containing the outbreak. Instead, it recommended reviewing the situation in three months to assess whether such assistance was necessary (Kamradt-Scott 2015: 75). What explains the delay in declaring a PHEIC? Notably, some officials in the WHO Regional Office for Africa (AFRO) had contacted WHO in May and June, recommending that it declare a PHEIC for Ebola. WHO declined to do so, arguing that such an action would damage its relations with affected states (Kamradt-Scott 2016: 406). Some staff members warned WHO against declaring a PHEIC, according to internal emails, because it ‘could be seen as a hostile act’ with negative economic and political repercussions and should be ‘a last resort’ (Associated Press n.d.). WHO essentially delayed its declaration because it thought the declaration would have negative effects on states—even though those countries were already experiencing significant negative effects from thousands of people falling ill and dying from Ebola with far too few resources to stop the outbreak’s spread and the fear that it generated. While it is important not to declare a PHEIC too hastily, the long delay in declaring a PHEIC for this Ebola outbreak undoubtedly allowed the disease to further entrench itself and slowed international coordination to address it (Siedner et al. 2015: 3). Compounding the earlier problems, the PHEIC declaration did not immediately change WHO’s response to Ebola. The organization did not implement new additional measures to help the affected states. It was not until 27 August that WHO announced its ‘Ebola Roadmap’, which outlined various strategies and plans to contain the virus (Kamradt-Scott 2016: 406). To some degree, the involvement of the United Nations Security Council and the decision to create the United Nations Mission for Ebola Emergency Response (UNMEER)—the first time the United Nations Security Council had authorized a mission solely for public health purposes—was a direct result of WHO’s delays and failures. One factor limiting WHO’s ability to respond more rapidly was a lack of financial resources. Because the overwhelming majority of the organization’s budget comes from voluntary contributions from member-states for specific projects as described in Chapter 4, WHO has very little flexibility to shift resources around when emergencies arise and no reserve funds on which it 122

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can draw. That means that when WHO needs to implement an emergency epidemic response plan, it must solicit additional donations from the international community. While it is trying to raise funds, though, the costs continue to mount—meaning that the organization then needs to ask for more money. On 31 July 2014, WHO announced that its Ebola response plan would require $71 million to implement. Less than a month later, on 28 August, it announced a new response plan of $490 million. When announcing the revised plan, WHO officials stressed that these funds were simply for stopping the spread of Ebola and would not cover the costs of rebuilding health care systems in the most-affected states (Reardon 2014). A few days later, UN officials estimated the cost of getting necessary supplies to stop the spread of Ebola at $600 million (Clarke and Samb 2014). By mid-November, the figure topped $1.5 billion to support UNMEER (Grépin 2015). Despite these failures and delays, the international community did respond to calls for emergency funding to respond to the Ebola outbreak. By the time WHO declared the end of PHEIC for Ebola, governments, intergovernmental organizations, and private actors had pledged more than $3.6 billion in humanitarian funding for the Ebola response according to accounting by the United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA) Financial Tracking Service—and the vast majority of funds had already been paid. While it took a while for WHO to collect pledged funds initially, the pace rapidly accelerated once systems were in place. Of the $3.6 billion pledged, less than $600 million remained outstanding when the PHEIC ended (United Nations Office for the Coordination of Humanitarian Affairs Financial Tracking Service 2017). This $3.6 billion figure reflects the total amount pledged for any element of the Ebola response. The UN plan, which worked through WHO and other specialized agencies, requested $2.27 billion for operations between October 2014 and June 2015. Of this amount, it received pledges of $1.56 billion (68 per cent of the total) and had received all but $140 million of the pledged amount by May 2016 (United Nations Office for the Coordination of Humanitarian Affairs Financial Tracking Service 2017). Poor relationships among the various actors responding to Ebola also hampered coordination and effectiveness. Before the Ebola outbreak, commentators described WHO’s 1+6 setup, whereby WHO is connected with but lacks authority over its six autonomous regional organizations, as a ‘structural morass [that] impedes program implementation’ (Davies and Youde 2015a: 248). The Ebola outbreak bore out many of these fears. Relations between WHO in Geneva and AFRO, based in Brazzaville, were particularly strained. Observers alleged that AFRO failed to help procure visas for WHO officials and emergency responders and that it blocked the disbursement of $500,000 in the early months of the international community’s response (Youde 2015a). WHO blamed AFRO for the problems with the initial response, describing 123

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the officials there as ‘politically motivated appointments’ with little interest in or knowledge of public health (Ahissou 2014). Tensions did not solely exist within WHO’s structures. WHO and MSF repeatedly presented very different pictures of the state of the epidemic in the region. During a meeting between MSF’s leader Joanne Liu and WHO Director-General Margaret Chan on 30 July 2014, Liu reportedly asked Chan to declare Ebola to be an emergency. Chan responded that Liu was being very pessimistic (Sun et al. 2014). This led to MSF loudly criticizing WHO for its tardiness and failure to live up to its organizational mandate. MSF called the international community’s response as led by WHO ‘slow, derisory, [and] irresponsible’ (MSF 2014). MSF was not without blame; it, too, found its operations coming under scrutiny. National governments also criticized MSF’s failures to liaise and communicate effectively with local and national officials, giving rise to tensions that further slowed the implementation of an effective response protocol (Hayden 2015: 18). By late August, the international response to Ebola was finally starting to take shape. UNMEER identified five strategic priorities, six principles, and twelve mission-critical actions to guide its response (United Nations 2014). WHO developed a three-phase response. The first phase, running from August to December 2014, focused on a rapid scale-up of the response by getting treatment centres and personnel to West Africa and improving social mobilization capabilities. The second phase, from January to July 2015, concentrated on increasing capacities for responding, emphasizing case finding, contact tracing, and community engagement. The third phase, from August 2015 to mid-2016, prioritized interrupting Ebola’s transmission chain. In all three of these phases, WHO emphasized the need for an interdisciplinary and multisectoral approach (World Health Organization 2016a). To achieve all of these goals, the international community would need to work together to get health care workers and financial resources into the region, establish specialized Ebola treatment centres, provide comprehensive training in infection avoidance measures, provide access to personal protective equipment, work with local communities to develop safe burial practices, undertake public education missions, and coordinate with a large number of governments, NGOs, and charities that all took a role in the response. It also required a response system that could adapt to the changing conditions on the ground. Hans Rosling, a Swedish statistician who worked with the Liberian government to interpret epidemiological data, quipped, ‘What we needed to do in the first phase was rugby. Now it is chess’ (Kupferschmidt 2014: 1039). In addition to WHO and UNMEER, donor states and NGOs were putting together their own action plans to support the international response to Ebola. The International Committee of the Red Cross implemented programmes to promote safe burial practices and raise public awareness of the disease. The 124

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United States, United Kingdom, China, and Germany, among others, deployed members of their militaries to establish Ebola Treatment Units (ETUs), bring supplies to the affected region, and provide logistical support. More than five thousand military personnel spent time in the area, and the American and Chinese militaries established sixteen ETUs (Kamradt-Scott et al. 2015: 26). Involving the military in the response to a public health emergency was unconventional, but US government officials argued that the military was the only organization that possessed the ability to move with the speed and scale necessary to get in front of the outbreak (Sun et al. 2014). The Bill and Melinda Gates Foundation pledged more than $52 million to support the international response, build local capacity, and invest in research for treatments and vaccines against Ebola. Paul Allen, who cofounded Microsoft with Bill Gates, personally pledged $100 million to support several Ebola response efforts through various channels. The Australian government contracted a private company, Aspen Medical, to staff and operate a British-built ETU (Harrison 2015). Unfortunately, the response plans did not always produce the intended results. While the American military built fifteen ETUs, the units only treated twenty-eight patients during their operation—and nine of them saw no patients (Gros 2015: 250). During the five months that Aspen Medical staffed the British-built ETU on Australia’s behalf, it saw only 216 patients at a cost of more than AUD84,000 per patient—nearly 8.5 times the per patient cost for organizations like MSF (Harrison 2015). NGOs also played significant roles in responding to Ebola in West Africa. In a number of communities, NGOs like MSF were already on the ground providing health care, so they were on the front lines when the first Ebola cases appeared. These pre-existing ties proved invaluable as part of the response, since it meant that these NGOs and their staffs already knew the local communities and had already established their legitimacy. At the same time, NGOs lack the resources or mandate to establish robust primary health care systems or engage in ongoing disease surveillance efforts (Benton and Dionne 2015: 227). ‘Members of medical NGOs such as Médecins Sans Frontières . . . may have access to information in certain cities or regions of developing countries, and they may be willing to share that information . . . but NGOs cannot be expected, and nor are they equipped, to amass epidemiological data on entire countries’ (Zacher and Keefe 2008: 50). As a result, NGOs face serious structural and financial constraints in their ability to provide care or engage in comprehensive disease surveillance. They can help bring attention to an issue and implement an immediate response, but they may not be able to sustain this over the long term. MSF was among the most prominent of the NGOs involved in the response to the Ebola outbreak. Joanne Liu, the president of MSF International, called the group’s Ebola response ‘one of MSF’s biggest emergency operations in [its] 125

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44-year history’ in a speech to the 2015 World Health Assembly (Liu 2015). The organization had some previous experience working in Ebola outbreaks, but it only had around forty experienced staffers when the disease emerged in West Africa (Westcott 2015). Over the first year of the outbreak, it deployed more than 1,300 international staff and 4,000 local staff to work in its Ebola treatment centres. It trained more than one thousand people to work in the treatment centres, and made more than half a million sets of personal protective equipment available (Kamradt-Scott et al. 2015: 26). Even with all of this, MSF’s human and physical resources were stretched to the limit. It saw fourteen of its staffers die from Ebola, and its facilities were so overwhelmed that they could only admit new patients for thirty minutes a day (Westcott 2015). One of the key roles played by MSF during the Ebola outbreak was getting the world’s attention. Liu used her position as the head of MSF to repeatedly chastise leaders and organizations that were not giving the epidemic the level of attention it was due. MSF also challenged WHO’s assertions in April 2014 that Ebola was largely under control (Youde 2015b). As late as October 2014, MSF officials declared that it was ‘ridiculous’ that NGOs and volunteers were still providing the bulk of care to Ebola patients (BBC 2014b). Liu specifically called on countries with expertise in biohazard containment to deploy their personnel. In a rare move for an organization that has long had an ambivalent attitude towards militaries, she specifically cited the importance of countries using both civilian and military resources (Torjeson 2014). Religiously affiliated charities also found themselves thrust into responding to the Ebola outbreak. Samaritan’s Purse and Serving in Mission (SIM), two Christian organizations that had been working in medical missions in Liberia for a number of years, rose to prominence—both because of their frontline treatment activities during the outbreak and the fact that two of their American staffers contracted the disease and were evacuated from the country. Both organizations had experience providing health care in developing countries, but neither had previous experience with Ebola (Dennis 2014). Because of the infections among Samaritan’s Purse and SIM missionaries, both organizations pulled back on their involvement with Ebola. Most of the foreign staff were removed from Liberia in July 2014. When they returned two months later, foreign missionaries largely concentrated on handling logistics and overseeing local staff instead of directly providing health services themselves. Franklin Graham, the president and CEO of Samaritan’s Purse, argues, ‘We believe if you’re going to fight Ebola, you’re going to have to train Liberians to save Liberians’ (Alford 2014). The decision by groups like Samaritan’s Purse and SIM shows the degree of fear experienced by health care workers involved with Ebola, an inability of NGOs to sustain long-term emergency responses, and a potential double-standard around the exposure to risk.

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Calls for Reform in the Aftermath of Ebola The failures of WHO—and the wider international community—in response to the Ebola outbreak prompted a collective recognition that the global health governance system needed to change. In particular, there were calls to reform WHO because of its mandate to coordinate and direct cooperative efforts on international health matters. In an effort to spur WHO to adopt significant and far-reaching changes, at least six independent review panels have issued recommendations for reforming WHO (Busby et al. 2016). The two most prominent are the independent Ebola Interim Assessment Panel, chaired by Dame Barbara Stocking, the former chief executive of Oxfam GB and a previous senior manager with the United Kingdom’s National Health Service, and the Harvard Global Health Institute–-London School of Hygiene and Tropical Medicine (Harvard–LSHTM) Independent Panel on the Global Response to Ebola, which brought together academics, policymakers, and civil society activists from around the world. The Harvard–LSHTM report identifies four key themes around which WHO should orient itself: preventing major disease outbreaks; responding to major disease outbreaks; research and the production and sharing of data, knowledge, and technology; and governing the global system for preventing and responding to outbreaks. Within these themes, they highlight ten reform recommendations: 1. Develop a global strategy to invest in and sustain national core health capacities 2. Strengthen incentives for states to report outbreaks early and base trade and travel restrictions on science 3. Create a unified WHO Centre for Emergency Preparedness and Response with adequate responsibility, capacity, and accountability 4. Move the process of declaring PHEICs to a politically insulated Standing Emergency Committee 5. Create an independent Accountability Commission for Disease Outbreak Prevention and Response to assess the global response to major disease outbreaks 6. Develop a framework of rules to govern and ensure access to research results 7. Create a global facility to finance and prioritize research and development 8. Establish a Global Health Committee within the United Nations Security Council to sustain high-level political attention to health concerns

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9. Give WHO a greater focus on its core functions and ensure that the organization has appropriate resources to carry out its missions 10. Demonstrate WHO’s credibility through decisive reforms and assertive leadership (Moon et al. 2015). These reforms, the report’s authors argue, will allow WHO to act as the hub for coordinating global health action, reassert its leadership in cross-border health issues, and facilitate more timely responses free from political interference and based on science. The Stocking Report called the need for WHO reform as ‘as a defining moment not only for WHO and the global health emergency response, but also for the governance of the entire global health system’ (World Health Organization 2015f: 8). Like the Harvard–LHSTM analysis, the Stocking Report concentrated its recommendations around three primary areas of concern: the International Health Regulations (2005); WHO’s health emergency response capacity; and WHO’s role and cooperation with wider health and humanitarian systems. Under these three categories, the report offers twentyone recommendations: 1. Propose a prioritized and costed plan to develop national core capacities required by the International Health Regulations (2015) 2. Strengthen all levels of WHO to independently identify and declare health emergencies 3. Consider providing incentives to encourage states to report public health risks to WHO early 4. Consider disincentives to discourage countries from introducing trade and travel restrictions beyond those recommended by WHO 5. Consider the creation of an intermediate-level international health alert short of declaring a PHEIC 6. Use the Secretary-General’s High-Level Panel on the Global Response to Health Crises to bring specific health matters to the Security Council’s attention 7. Increase assessed contributions from member-states by 5 per cent 8. Create a $100 million contingency fund for health emergencies, funded by voluntary contributions 9. Make sure WHO’s budget and organizational structure fit its health emergency response mandate 10. Develop an organizational culture that accepts WHO’s emergency response mandate

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11. Establish a WHO Centre for Emergency Preparedness and Response to develop procedures to achieve full response and preparedness capacities 12. Create an independent board to oversee and guide the Centre for Emergency Preparedness and Response 13. Build greater capacity at the country office level, including structures to support country directors in having an independent voice 14. Communicate health emergencies to the international community in a rapid, complete, and accurate fashion 15. Put appropriate community engagement at the centre of health emergency responses 16. Play a central role in encouraging research and development to respond to future health emergencies 17. Maintain high alert levels in response to the ongoing Ebola crisis 18. Coordinate WHO’s declarations of health emergencies with other humanitarian agencies to facilitate better cooperation among organizations 19. Develop a better understanding of the existing humanitarian response systems 20. Ensure that the larger humanitarian system understands the special nature of global health risks 21. Encourage the Secretary-General to appoint a Special Representative or Special Envoy to oversee greater financial and political engagement by the international community during health crises (World Health Organization 2015f). As with the Harvard–LSHTM report, the Stocking Report positions its recommendations as vital to helping WHO rebuild its capacity and legitimacy within the international community. It also suggests, much like analyses written prior to the Ebola outbreak (Davies and Youde 2015a), that WHO needs to right-size itself and concentrate on those areas in which it has a comparative advantage. Looking at the recommendations from these two reports, commonalities quickly emerge. Both recognize that an assessment of WHO’s mandate reveals significant underfunding and call for changes in its funding structures. Both place an emphasis on WHO’s central role as an information provider and distributor for the international community. Both argue for the need to introduce changes within WHO’s bureaucracy, calling for the creation of new coordinating offices and additional politically insulated advisement bodies. Finally, both recognize that the operational expectations of what WHO can and should do outstrip its mandate and that the organization should focus on its areas of core competency. The Ebola outbreak did not cause these problems that WHO,

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and global health governance more broadly, were facing, but it made the flaws in the system glaringly obvious and in need of attention. While these proposals offer a number of timely and potentially useful suggestions, it is also telling what they do not address. Despite the obvious importance of non-state actors and other organizations working outside WHO’s orbit in addressing the Ebola outbreak, and despite the noted difficulties in coordinating actions between WHO and other important actors in the global health space, there is almost no attention paid to establishing better coordinating mechanisms to facilitate smoother cooperation between WHO and other groups. This absence likely reflects tensions within WHO over the appropriate role of NGOs and other non-state actors, but it is also a clear demonstration of the continuing difficulties in reconciling both pluralist and solidarist impulses within an institution of international society. Regardless of the merits of these proposals, the panels have no power to actually implement changes directly themselves. They are merely offering suggestions to the World Health Assembly, the deliberative body that brings together representatives of all the member-states on an annual basis to set WHO’s budget and direct the organization’s activities for the next year. WHO members have shown themselves resistant to many of the reforms. For example, member-states roundly rejected Director-General Margaret Chan’s call for a 5 per cent increase in assessed dues and warned her to remove it from her proposed budget (Kamradt-Scott 2016: 411). While the organization’s overall budget has increased, that increase came entirely from voluntary contributions from member-states with their own specific demands and programmatic interests (Garrett 2015). What is significant, though, is the level of engagement around improving global health governance in the future. International society collectively recognizes that the response of WHO was inadequate, that NGOs can play an important role in actuating an international response, and that cross-border coordination and cooperation are vital when these sorts of emergencies arise. It also recognizes the need to improve these systems. Rather than seeing global health governance as something needed merely on an ad hoc basis, international society is taking the failures of its response to the Ebola outbreak as an opportunity to improve the situation in the future. Global health governance and its importance to the international society is taken as a given. The question is not whether there should be a robust global health governance system; the question is instead how to make the existing more robust and resilient so that it can respond to the challenges that arise. International society is focused on identifying the appropriate role for WHO and its place vis-à-vis other global health actors. Kickbusch describes the post-Ebola global health landscape as a potential turning point, one in which international society can

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move forward to address health in a holistic manner and with an appropriate level of resources (Kickbusch 2016). While it remains to be seen what (if any) reforms will occur within WHO and the effects that those reforms will have on global health governance systems, WHO’s failures in response to Ebola have shone a spotlight on the existing inadequacies within the system. They are forcing international society to reckon with the distinction between its ideals about global health governance and the practical realities of what that system can actually do. The gap between intention and application mirrors the one Vincent identified in the 1980s around human rights or Gonzalez-Pelaez noted in relation to hunger and access to food twenty years later. The fact that an institution within international society is not living up to its potential or is not entirely fulfilling its mission does not mean that the institution does not exist. Institutions, be they primary or secondary, will occasionally fail to live up to their expectations or goals. Rather than providing evidence of failure, this signals contestation. It shows how international society is struggling amongst itself about where the institution sits on the solidarist/pluralist continuum.

Conclusion The experience with Ebola and the post-pandemic soul-searching being done by international society also shows why it is most appropriate to conceptualize global health governance as a secondary institution that is connected to a primary institution of moral obligation and responsibility. The issues in global health governance largely swirl around understanding how best to put the ideas of the primary institution of moral responsibility into practice within international society. Recalling Spandler’s argument that secondary institutions are ‘sets of discursively formulated expectations’ that are ‘temporally and spatially discrete sections of international reality and apply to a clearly defined set of actors’ (Spandler 2015: 613), it is apparent that global health governance fits within this framework. The evaluations in the aftermath of the lacklustre Ebola response are efforts to reaffirm and re-establish the discursively formulated expectation and to ensure that the clearly defined set of actors who address global health governance can navigate this realm better in the future. Global health governance in and of itself is not a primary institution, but it contributes to these regularized patterns and behavioural expectations around moral obligation and responsibility and the need for states to respond to emergencies and crises in other states. Global health governance’s role as a secondary institution operates as a constitutive element in a specific area of

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concern that speaks to the larger conceptions of responsibility and obligation that exist in contemporary international society. Chapter 7 looks at the dynamics around China’s involvement in global health governance. The Chinese government has been actively involved in various global health efforts, particularly through its health diplomacy efforts in Africa, but it has expressed a wariness towards some of the larger global health governance organizations. At a time when its economic stature could give it a larger role in global governance, it is reluctant to do so. It also speaks to larger debates about the role of non-European states in international society and the steps such states would need to undergo in order to be accepted as an equal partner.

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7 China, International Society, and Global Health Governance

When it comes to global health governance, the People’s Republic of China (PRC) occupies a unique position—a uniqueness derived from its ambiguous relationship to the institution. It is one of the world’s most populous countries with one of the largest economies and a seeming desire to play a larger role in global governance. At the same time, though, China tends to portray itself as a leader of the Third World and has not availed itself of opportunities to take a leadership role on global health governance issues. It is a country that both contributes to and receives aid from global health governance institutions. It has explicitly incorporated health into its foreign policy, deploying medical teams to countries around the world to improve access to health care and promote its own soft power, and it actively promoted the candidacy of Margaret Chan for the role of Director-General of the World Health Organization (WHO) (Chan 2011: 148). That has not translated, though, into a willingness to proactively collaborate with the values and norms embodied within international society’s global health governance structures. It has repeatedly shown a reluctance to collaborate with surveillance systems or engage in other information-sharing activities that are at the heart of contemporary global health governance. Such ambivalence highlights the importance of figuring out where China fits within the larger global health governance system. China is incredibly important to global health. Huang notes that China possesses one-fifth of the world’s population, contains one-seventh of the world’s disease burden, and has been the origin site for a number of international infectious disease pandemics (Huang 2010: 106–7). The country obviously has a vital role to play—not only in keeping its own citizens healthy, but also in protecting people around the world—but its engagement with international society’s global health governance architecture remains uncertain. A failure to include China in these structures could undermine global health governance’s ability

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to combat disease outbreaks, but such thinking also assumes that the Chinese government has an interest in engaging with global health governance structures as they currently exist. Former Premier Wen Jiabao has spoken of the need to create ‘a model of developing foreign aid with Chinese characteristics’, but it is unclear what exactly this model would look like or how it would relate to the existing global health governance system (Clark 2014: 318). Does engaging with global health governance require China to embrace the system as currently constituted, or can it alter the system in such a way to benefit itself and the rest of international society? These ambiguities about China’s place in global health governance reflect larger questions about the relationship between China and international society. China has both shown an interest in being an active member of international society and emphasized its difference and distinctiveness from the existing international order. This uncertain relationship with international society writ large reflects the fact that the country is frequently speaking to multiple audiences—the developed, largely Western states that sit at the centre of international society and the Third World states of which China claims to be a leader and exemplar of the benefits of resisting Western models of development (Suzuki 2008: 56–8). China is hardly the only country to challenge some of the existing norms and practice within international society, nor is it the only newcomer to global health governance. Acharya and Buzan note that many non-Western countries do not fall neatly into existing international relations theoretical categories and that South Korea and India in particular seem uncertain ‘about what sort of place [they] want for [themselves] in international society’ (Acharya and Buzan 2007: 290). Merke (2015) describes how Brazil possesses shared values and institutions with its neighbours, providing the potential foundation for a distinct South American regional international society. Within the realm of global health governance, Fidler (2010b) argues that the rise of Asia—led particularly by China and India—has largely been disconnected from health so far, but that health is likely to become a more important issue. He emphasizes, though, that Asia’s increasing interest in global health is not unique to that region alone; it instead reflects ‘the general increase in global health’s foreign policy, diplomatic, and governance importance over the past 10–15 years’ (Fidler 2010a: 292). Harmer et al. (2013) show that the BRICS economies—Brazil, Russia, India, China, and South Africa—are becoming more important in global health both as funding sources and as institutional and ideational influencers. Kirton et al. (2014) reaffirm this argument, showing that BRICS states are using their regular summits to increase attention to global health governance and bring their influence to the issue. With all of this interest in how non-Western states attempt to influence international society and global health governance, a specific focus on China 134

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makes sense for three reasons. First, the sheer size of China’s economy gives it a great deal of power and opens conversations about its role in funding institutions within international society. Second, China holds a degree of political influence within the international system that exceeds other nonWestern states. Third, China’s historical experiences mean that these questions about international society and global health governance have featured prominently in Chinese politics since the nineteenth century. This chapter will examine the place of China within global health governance by examining its interactions with international society on global health issues, its development assistance for health (DAH) spending and priorities, its use of health in its foreign policy objectives, and its relationship with the various institutions of global health governance. It will highlight the fact that China’s ambiguous relationship with international society’s global health governance architecture may actually serve some of its perceived interests, but that this same architecture can and should adjust to incorporate China. International society, in all of its facets, exists within a ‘normatively unsettled condition’ (Clark 2014: 338), and the global health governance elements are no different. In examining China’s place within international society’s norms and values on global health governance, this chapter will pay particular attention to two elements: China’s use of health diplomacy in Africa, and its membership in, diplomatic activities with, and financial contributions to the leading institutions of global health governance.

China and International Society Historically, international society has grappled with understanding how and whether non-European states like China fit into its structures. Prior to the nineteenth century, Gillard argues that China was at the heart of its own regional system of states. Though its governmental structures differed from those in Europe, China’s influence over East Asia led other governments in the region to acknowledge the power and importance of the Chinese emperor in establishing and preserving world order. In this way, it maintained a relative degree of stability in the region even in the face of incredible power imbalances with other states like Japan (Gillard 1984: 87–8). During this period, China remained fairly impervious to European influence despite strenuous missionary efforts; rather, Chinese culture had a strong influence among liberal intellectuals in Europe (Watson 1984: 23). This situation changed during the nineteenth century. China had long asserted that it would engage with Europe along the same lines as it engages with any non-Chinese polity, and this standard generally worked. So long as European interests paid tribute to the emperor, there would be an opportunity 135

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for negotiation between China and outside governments (Gong 1984: 130–1). As the nineteenth century progressed, though, European states began to emphasize a standard of ‘civilization’ that would alter the terms on which it could engage with China. Instead of being a site for art and enlightened governance, Europe came to see China, and Asia as a whole, as ‘decadent’. No longer was there an allowance for multiple international societies. Instead, European governments equated modern civilization with their own standards and defined those practices as constitutive of international society. Therefore, only those governments that embraced European ideals could be part of international society and therefore worthy of mutual respect (Watson 1984: 27). Gong identifies five requirements for a state to meet this new standard of civilization: 1. Guarantees of basic rights like life, property, freedom of travel, freedom of commerce, and freedom of religion (particularly for foreign nationals) 2. An ‘organised political bureaucracy’ that can operate efficiently and provide some degree of self-defence 3. Adherence to ‘generally accepted international law’ (including laws of war) and the presence of a domestic legal system with equal justice for both foreigners and citizens 4. Maintenance of ongoing and permanent diplomatic exchange and communication with other states 5. Conforming to generally ‘accepted norms and practices of the “civilised” international society’, such as prohibitions on polygamy and slavery (Gong 1984: 14–15). By and large, though, they reflected European liberal thought in the nineteenth century—and took those ideas as given without consideration of different philosophical traditions. They elevated individual rights, for example, above collective rights and duties (Gong 1984: 20). These standards lacked specificity, allowing European states to manipulate their interpretations of them to deny recognition or respect to non-European states as they saw fit. As time has gone on, the standard of civilization has continued to evolve to equate political and economic performance with liberal democracy, market economy, and respect for international law as the new benchmarks for post-Cold War international society (Stivachtis 2015: 132–4). Others have argued that the new standard of civilization includes certain human rights standards, as evidenced by their status as a basic requirement for joining international organizations like the European Union (Donnelly 1998; Stivachtis 2008). Zhang describes this as ‘the expansion of international society 3.0’, based more on the expansion of ideological collective judgements rather than a simple geographic expansion (Zhang 2014: 678–9). These standards thus 136

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continue to be a tool that the West can use to deny recognition or respect to other states. The development of this standard of civilization for membership in international society in the nineteenth century fundamentally challenged China and began its bifurcated relationship with international society. With the Opium War of 1839–42, Europe’s attitude towards China underwent a dramatic transformation (Hsu 1995: 14). European international society fundamentally rejected China’s existing political, social, and economic practices and denied that China’s practices qualified as civilized (Gong 1984: 146). To be accepted by European states, China would have to conform to European rules and standards. China was ‘able to retain [its] independence at the price of Westernization’ (Watson 1984: 29). While China resisted relinquishing its own vision of civilization as long as it could, it gradually came to adhere to elements of the European standards. In the face of the unequal treaties imposed by foreign states and threats of external force, China began to ‘employ the European standard to enter international society as a “civilised” state’ in a strategic manner that did not entail wholesale acceptance of this standard of civilization (Gong 1984: 147). This is where the bifurcation emerges. China wanted both to be a part of international society and simultaneously to remain aloof enough from it so as to model an alternative path. China did enough for recognition, but it also contributed to and supported twentieth-century efforts by non-Western societies to challenge Western standards for membership in international society (Bull 1984b: 219–23). China’s inside/outside attitude towards international society has remained remarkably consistent since the nineteenth century. This is all the more remarkable given the radical changes the government has undergone—from the imperial system to the nationalist republic founded by Sun Yat-sen to the proclamation of the communist PRC in 1949 and the shifts in the PRC’s attitude towards international relations throughout its existence. Bell describes China’s ambiguous relationship with international society as ‘a case-study of continuity rather than change’ (Bell 1984: 255). In its contemporary manifestation, the Chinese government has largely argued that it is not a status quo power within international society because ‘the current rules of international institutions are systematically weighted against the interests of the developing world, with the more powerful states imposing their favoured liberal rules on the weak’ (Lee and Chan 2014: 298). It instead aspires for recognition as an established power on equal footing with Western states, despite the differences in political and economic forms, while maintaining the idea that it is an aggrieved state whose experience allows it to represent the interests of developing states (Lee and Chan 2014: 304). Suzuki describes this attitude as one of ‘Occidentalism’, whereby Chinese officials recognize Western standards as the sole benchmark for success and 137

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recognition within international society—even while they maintain an ambivalence towards the appropriateness of those standards for themselves (Suzuki 2014). China finds itself caught between a twin dynamic of receptivity and resistance to the institutions of global governance that are at the heart of international society (Tan et al. 2014). It has made some overtures towards engaging more fully with international society, but these efforts tend to be marginal and more concerned with protecting its own domestic interests (Buzan 2010: 14–15). This leads to a different vision of global governance and international society for China as opposed to that articulated by Western states. China recognizes that there exists an idea that its rise poses a fundamental challenge and threat to international society as currently known, so it has adopted a two-pronged strategy to counter that rhetoric. First, it aims to join as many major international organizations and treaties as possible to demonstrate that it is a responsible power. Second, it acts as the protagonist within international organizations, using its membership to point out unjust rules, emphasizing the importance of respecting and defending sovereignty, and fostering the formation of an Asian regional community (Chan et al. 2012: 33). It leverages the fact that ‘no global problems can be successfully handled without China’s involvement’ while also recognizing that it lacks the power to alter the rules of the game or change the international agenda on its own (Chan et al. 2012: 1, 33). The key question for China and international society remains, ‘Could the growing power of China, the most populous developing country in the world, be manifested in facilitating progressively greater global social justice and human welfare in the evolving architecture of global governance?’ (Chan et al. 2012: 3). One issue frequently brought into the conversation when discussing China’s place within international society is how and whether the size of its economy translates into political standing and stature. In 2016, the US Central Intelligence Agency (CIA) estimated the size of China’s gross domestic product at purchasing power parity exchange rates at $21.27 trillion. This makes China the largest economy in the world, outpacing the combined European Union economy by $2 trillion and the United States by approximately $2.5 trillion (CIA World Factbook 2017). This is incredible growth. In 1980, shortly after China introduced a number of post-Mao economic reforms, the International Monetary Fund estimated China’s gross domestic product at purchasing power parity exchange rates at $247.89 billion (Sedghi 2012). In that same year, the US economy was worth $2.82 trillion (Knoema 2017). China’s incredible economic growth has brought with it both a sense that the country is or should be a major player in the international arena and an expectation that it would become a larger contributor of resources and personnel to leading international organizations. Chan et al. argue that this 138

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growth is what gives China a place at the international table, writing that ‘China’s ability to play a significant role in global governance depends very much on its continuing economic growth’ (Chan et al. 2012: 59). That said, with China’s growing economic stature comes the notion that its increased prosperity should translate into larger contributions to efforts to address transnational problems (Tan et al. 2014: 325). So far, the Chinese government has tried to strike a balance. While it continues to receive loans from the World Bank, the Chinese government has increased its foreign aid to developing countries and suggested that it would agree to raising its World Bank contributions in exchange for more voting power (Chan et al. 2012: 62–3). It has also increased its personnel contributions to UN peacekeeping operations, but it has resisted increasing its financial contributions to support such missions (Chan et al. 2012: 43). Suzuki calls such a strategy one of playing ‘recognition games’, taking actions that demonstrate that China wants to be a part of international society without fully committing to its values and norms (Suzuki 2008: 46). While China has shown some willingness and interest in engaging with international society, its hesitation to fully embrace the system can be traced back to some of its existential commitments. China’s Five Principles for Peaceful Coexistence summarize these bedrock beliefs in a tidy fashion: • • • • •

mutual respect for territorial integrity and sovereignty mutual nonaggression mutual non-interference in domestic affairs equality and mutual benefit peaceful coexistence.

Uniting these five principles, though, is the country’s unwavering belief in respect for sovereignty above all else (Lo 2010: 17). Yoon describes China as hypersensitive to infringements on its sovereignty and ever vigilant about external interference in domestic politics (Yoon 2008: 86–7). As a result, China prioritizes sovereignty and nationalism over global governance when it perceives a conflict between these impulses (Yoon 2008: 96). The emphasis on sovereignty also leads to suspicion about the role of NGOs and civil society groups that operate outside the government’s control. The Chinese government views NGOs as lacking in legitimacy, and some elites fear that NGOs could eventually morph into political parties that would challenge Communist Party rule (Chan et al. 2012: 100–1; Lynch 2009: 103). Chan et al. explicitly connect this attitude with English School theorizing: On a theoretical level, the Chinese notion [of the international system] bears a resemblance to the English School’s pluralist conception of international society, in which sovereign states can maintain international order, in spite of the fact that they hold varying conceptions of human rights and global justice. (Chan et al. 2012: 37)

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This would align the Chinese government, or at least some members of the Communist Party elite, with the pluralist camp of English School theorizing (Lynch 2009: 105). While China’s ambiguous relationship towards international society can lead to an unsettled attitude, it is important to remember that international society itself is not unchanging. International society is not a purposeful reified agent, but it ‘has real-life effects as if it were’ because it ‘acts’ through its socialization processes (Clark 2014: 320–1). Both international society and the PRC (and all other actors within the international arena, for that matter) engage in ‘perpetual co-constitution’ and operate within a space which remains contested and unsettled by design (Clark 2014: 337). This means that the perceived discordance between China and international society is not an unalterable fact. It also suggests that growing ties between China and international society do not depend solely on China embracing international society’s values and norms. Rather, international society can and will change. It would be a mistake to assert that challenges to European dominance within international society are symptomatic of the breakdown of international society or that non-European states are the only ones who want to see the norms and values embedded within international society change (Bull and Watson 1984a: 433). Dunne notes, ‘The future may well belong to the liberal international order, but there is nothing natural or inevitable about this process’ (Dunne 2010: 537). International society’s continued growth and sustenance will depend on moving beyond its roots in modern European political, legal, and philosophical traditions to identify ways to incorporate ‘the others’ into the realm (Zhang 2011: 785). As the PRC has sought to demonstrate its desire for some modicum of membership in international society’s norms and values specifically related to global health governance, it has concentrated its efforts in two key areas. First, it has engaged in health diplomacy, building bilateral relationships with African states and deploying medical teams to those countries to improve access to medical care and build stronger relationships. Second, it has taken more deliberative steps to engage with leading organizations of global health governance in recent years. While the Chinese government remains a relatively small financial contributor to most of these organizations, receiving more in aid from them than it gives them itself, and has largely avoided steering the organizations’ overall agendas, it has consciously cultivated membership and sought to demonstrate its engagement on some level. The Chinese government has not necessarily wholly embraced the norms and values embedded within international society’s ideas about global health governance, but its engagement shows an interest in being a part of that same international society and helping to guide the vision of what its norms and values will be. 140

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China and Health Diplomacy in Africa States are increasingly integrating health into their diplomatic strategies. Health is moving from being auxiliary or an afterthought to a more central location. Governments seek to use health diplomacy to extend both their hard and soft power. Health diplomacy is ‘political activity that meets the dual goals of improving health while maintaining and strengthening international relations’ (Novotny et al. 2008: 41). Others have described it as ‘mechanisms to manage the health risks that spill into and out of every country’ (Drager and Fidler 2007: 162). This approach moves beyond an explicit focus on particular illnesses and instead accentuates how various manifestations of ill health can have negative consequences for the international community. Health diplomacy is not necessarily premised on enlightened self-interest, though. States can engage in health diplomacy to further their own interests—with an added humanitarian benefit. Drager and Fidler (2007), for example, concern themselves a great deal with the connections between health and international economics, but they do so from a perspective that acknowledges that healthier countries are more economically productive and better able to engage with others on that level. This shift towards emphasizing health diplomacy is perhaps most strikingly illustrated by the relationship between the PRC and African states. China’s support for various African health care systems has ebbed and flowed over the past fifty years, but it has come to assume a prominent place—just as the government has sought to increase its political influence, economic footprint, and access to natural resources throughout the continent. Providing health care resources not only helps China gain favourable trading terms and access to necessary resources, but it also supports the government’s attempts to portray itself as a good international citizen. It is this combination of hard and soft power—economic and ideological benefits—that marks a significant change in China’s health diplomacy strategies. It also allows China to engage with elements of global health governance and international society in its own particular way. From the beginning of Chinese diplomatic involvement in Africa, it has sought to frame its relationships over time with African governments and anti-colonial movements as a counterweight to the perceived hegemonies of both the United States and the Soviet Union. The Chinese government presented itself as a patron who both rejected the imperial mandates of Western powers and understood the unique struggles of ‘peasant movements’, unlike the Soviet Union. It portrayed itself as challenging the dominant conceptions of international society that existed in the thick of the Cold War. This diplomatic engagement extended to supporting infrastructural development through deploying medical teams throughout the continent. In 1963, Zhou Enlai dispatched the first Chinese medical teams to Algeria, inaugurating Chinese efforts to support African health care systems by providing 141

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medical personnel, equipment, and supplies (Eisenman 2007: 43–4). In some instances, the arrival of medical teams coincided with other Chinese infrastructure- or economics-based diplomatic involvement in Africa. More often, though, medical teams were deployed following treaty negotiations between China and the receiving state absent any ostensible economic benefit. The Chinese medical teams frequently were sent because the host country expressed an inability to live up to its health care commitments (Jennings 2005: 461). In its efforts to support the development of health care infrastructures throughout Africa, China claimed it wanted to avoid imposing its own vision of medical care. Instead, it sought to encourage development based on the country’s own unique characteristics and locally appropriate technologies (Carmody and Owusu 2007: 508; Gill et al. 2006: 20). Chinese medical personnel were generally deployed in the receiving country for a two-year term, often serving in rural, underserved communities. In addition to sending general practitioners, these teams frequently included a broad array of specialists (Hsu 2008: 222–3). While the Chinese national government negotiated the agreements, the actual implementation of these agreements fell to individual provinces. Particular Chinese provinces were linked with one or more particular African countries (Thompson 2005). In this way, the government sought to establish long-term ties between African states and Chinese provinces. It was the provincial government’s responsibility to recruit personnel, send equipment, and ensure smooth exchanges. Since the province was responsible for implementing the agreements, the idea was that establishing ongoing relationships would ease logistical challenges and build longstanding relationships. Under the terms of most of the medical cooperation agreements, the receiving state paid the expenses for the medical team. These included international airfares, stipends for the doctors and support staff, and some of the pharmaceuticals and medical equipment brought by the team. On occasion, the Chinese national government covered these costs through loans or grants. More often than not, though, these costs came directly from the national health care budget (Thompson 2005). Though China paid less attention to Africa in the 1970s and 1980s, it began a concerted process to re-engage with its African allies beginning in the 1990s. As part of this re-engagement, the Chinese government emphasized its status as a natural leader of developing states and the only viable alternative to neoimperialist strategies (Youde 2010b: 155–6). Health diplomacy has played a prominent role in these efforts. Government leaders from China and forty-five African states met in Beijing in October 2000 for the inaugural Forum on China–Africa Cooperation (FOCAC). At the conclusion of the meeting, the Chinese government forgave US$1.2 billion in foreign debt owed by African states and pledged to increase its aid contributions to the continent in all realms, including health. Three years later, when the FOCAC re-convened in 142

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Addis Ababa, the Chinese government made more explicit health diplomacy promises. It specifically highlighted the treatment and prevention of disease as one of its priority areas, pledging additional funds for these efforts (Sutter 2008: 373). Health also featured prominently at the third FOCAC meeting in November 2006. Not only did the Chinese government pledge to double its aid to Africa by 2009 and offer US$5 billion in preferential loans to the continent, but it also emphasized the prominent role of health and education programmes in its African aid efforts (Sutter 2008: 373). At this same meeting, the Chinese government pledged to build thirty hospitals in Africa, provide US$37.5 million in grants for anti-malarial drugs (drugs, incidentally, developed and manufactured in China), and develop thirty demonstration centres for the treatment and prevention of malaria. It also renewed its commitment to continue sending medical teams (People’s Daily 2006a). Public health and medical care again played a prominent role in the final action plan after the 2015 FOCAC Summit in Johannesburg. The representatives of the assembled African governments ‘expresse[d] [their] appreciation for China’s continued assistance to countries in need . . . and further appreciate[d] China’s continued support to reconstruct public health, economic, and societal systems of the affected countries during the post-Ebola period’. The Chinese government pledged a number of specific steps that it would undertake to support African health systems, including: 1. Assist with the improvement of disease surveillance and epidemiological systems 2. Strengthen efforts to prevent and treat malaria and other infectious diseases 3. Support cooperation between twenty Chinese hospitals and twenty African hospitals on demonstration projects 4. Continue training doctors, nurses, and other health care workers for Africa 5. Support building an African Union Centre for Disease Control and Prevention and other efforts to enhance the continent’s medical research and diagnostic capabilities 6. Continue sending medical teams from China to African states 7. Encourage joint medical and pharmaceutical efforts between Chinese and African firms 8. Improve health infrastructure throughout the continent 9. Improve access to maternal and child health and reproductive health services 10. Facilitate high-level exchanges between health policy makers (Forum on China–Africa Cooperation 2015a). 143

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To support China’s ambitious plans for health and other sectors in Africa, President Xi Jinping announced that his government would make available $60 billion in various funding support programmes (Forum on China–Africa Cooperation 2015b). This is a tripling of the funding that China has previously made available after FOCAC meetings (Sun 2015). The medical teams China pledged to send are particularly crucial to its health diplomacy efforts. Each Chinese provincial government is paired with one or more African states and is responsible for staffing and supporting medical teams in its partner state. After dwindling in the 1980s, Chinese medical teams have been increasingly deployed throughout the continent. In 2003, 860 Chinese medical personnel were serving in thirty-five teams in thirtyfour African states. Two years later, the number of Chinese medical personnel in Africa topped nine hundred (Eisenman 2007: 44). By 2014, researchers estimated that the Chinese government was spending $30 million to $60 million to support forty-three medical teams in forty-two African states (Lin et al. 2016). When sending these medical teams, the Chinese government strongly emphasizes its solidarity with Africa. China calls upon its self-perceptions as a developing country as proof that it has no grander, hegemonic motivations in deploying medical personnel on the continent. During remarks made with Jose Maria Neves, the prime minister of Cape Verde, then-Premier Wen Jiabao remarked that China is itself a developing country with limited resources. He continued, ‘the assistance we have provided to the best of our ability is therefore sincere and selfless’ (Ministry of Commerce of the People’s Republic of China 2006). At the same time, the Chinese government has not wholly dismissed the larger international society in its approach. While it may portray itself as an alternative model, it highlights its commitment to the norms, values, and goals of global health governance in international society by connecting its actions to global interests. It has connected the deployment of its medical teams to larger international goals. At a 2009 diplomatic conference, Ambassador Liu Zhenmin, China’s deputy permanent representative to the United Nations, stated that his government’s deployment of medical teams would not only help African states weather the global economic crisis, but also make it more likely that those countries would achieve the targets established by the United Nations in the Millennium Development Goals (Permanent Mission of the People’s Republic of China to the United Nations 2009). In addition to traditional medical teams, the Chinese government started to include its medical personnel on UN peacekeeping missions in Africa. Nearly nine hundred Chinese medical personnel served on eight UNsponsored African peacekeeping missions in 2005 (Sutter 2008: 375). In 2016, China’s People’s Liberation Army deployed just over 2,600 personnel on UN peacekeeping operations, and the majority came from engineering, 144

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transport, and medical teams (Blasko 2016). It now ranks as the largest contributor of medical personnel to UN peacekeeping missions around the world (Van der Putten 2015: 14). These troops contributed both to benefiting health care infrastructures in African states and demonstrating China’s willingness to engage with the international community in a constructive, cooperative manner. More recently, the Chinese government turned to the People’s Liberation Army to provide assistance in West Africa to combat Ebola. Troops worked to construct health facilities, military scientists conducted research on treatments for and vaccines against Ebola, and much of China’s aid to combat Ebola was funnelled through the military (Tiezzi 2014). Providing these medical teams appears to be paying off for the Chinese government and its efforts to improve its standing among developing nations. It not only provides much-needed services to a large swath of the population in Africa, but it also reaches far more people than other outreach programmes can. Thompson acknowledges, ‘While university scholarships promote closer ties between China and Africa, China has also promoted “health diplomacy” with African partners, establishing a relationship between Chinese doctors and millions of ordinary Africans, and earning the gratitude of many African leaders eager to be seen providing public goods to their citizens’ (Thompson 2005). Public opinion suggests that these actions have benefited China’s reputation throughout Africa. In 2014 and 2015, 63 per cent of respondents in thirty-six African countries described China’s influence in their country as somewhat or very positive. China’s efforts to promote infrastructure and development were the most important reasons for these positive attitudes (Lekorwe et al. 2016). In this instance, providing health services allows the Chinese government to grow in stature among the people and government leaders throughout the African continent. Part of what makes China’s health diplomacy strategy so interesting is how it simultaneously pursues insider and outsider strategies. It positions its bilateral appeals to developing states in the context of a shared experience and a commitment to resisting imperialism, but it also emphasizes how its efforts work towards satisfying global health goals. It shows evidence of an interest in participating in international society or at least abiding by some of its norms and values, but without completely rejecting its own traditions and values. China’s health diplomacy efforts in Africa in many ways mirror the government’s larger attitudes towards global health governance and international society.

China and Global Health Governance Institutions The ambiguous relationship between the PRC and international society replicates itself within the realm of global health governance. On the one hand, 145

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the Chinese government recognizes the value of participating in global health governance institutions and has taken steps to demonstrate its willingness to embrace some of the norms, values, and expectations that exist within the global health governance architecture within international society. On the other hand, its prioritization of state sovereignty and nationalism has discouraged more active collaboration with these same institutions. Given the realities of combatting transnational health concerns and the history of infectious disease outbreaks in recent years, it is incumbent upon both China and international society to find a way to embrace each other to strengthen global health governance. Analysts of global health governance frequently lament China’s reluctance to take a stronger leadership and financial role within the international system. Yoon argues that China tends to respond to infectious disease outbreaks with policies that emphasize national protection over international cooperation. The government views disease outbreaks as weakening national power and construes national power as a zero-sum game. As such, sharing information about disease outbreaks with international society would give other states the tools and information necessary to take advantage of China’s situation and usurp its power (Yoon 2008: 93). Stevenson and Cooper note, ‘Although China aspires to be a global leader, it continues to work to constrain the application of exogenous norms’ in global health governance (Stevenson and Cooper 2009: 1380). They argue that global health governance institutions emphasize the notion that health is a human right that should be protected by the state and that public health is key for collective security in a globalizing world. The Chinese government, by contrast, makes healthrelated policy changes solely based on its own political and economic calculations and invokes a sovereign right to self-determination as it sees fits (Stevenson and Cooper 2009: 1383–5). Lee and Chan echo this view, arguing that China stays on the periphery of global health governance because of its dualistic national identities and its efforts to present different images of itself to different audiences. They describe a group they call Chinese realists or ‘China Firsters’ who interpret any effort to get China to contribute more financially to these institutions ‘is a trap [by the West] to exhaust [China’s] limited resources’ (Lee and Chan 2014: 306). This has discouraged Chinese health experts from collaborating with global health governance, which further isolates the government from the larger global health governance architecture. The result is an attitude where the government is simultaneously fearful about being left behind but also unmotivated to participate in efforts to reshape global health governance institutions (Lee and Chan 2014: 306–9). Even when there have been conscious efforts to reshape global health governance’s institutions within international society, China has tended to be conspicuously absent. During the 1990s and 2000s, WHO undertook a 146

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massive effort to fundamentally rewrite the International Health Regulations (IHR)—a process described in Chapter 3. Despite the fact that this was one of the largest global health diplomacy efforts undertaken to this point, China had relatively little involvement in the IHR revision process. It did not take an active role in the IHR negotiations, and it offered little experience or expertise to inform the debates (Lee et al. 2012: 350). What makes China’s minor role in the IHR revision process all the more curious is that much of the final impetus for overhauling the IHR came from China’s experience with SARS. SARS was ‘a good example of an “exogenous shock” ’ to international society and global health governance, demonstrating the need for the system to change to respond to new challenges (Price-Smith 2009: 15). In this case, the Chinese government’s efforts to cover up the extent of SARS’ spread, its reluctance to cooperate with international organizations, and its obfuscation to domestic and international audiences provided international society with the final validation that it needed to change its norms and expectations regarding disease surveillance (Davies et al. 2015: 45–58). Thus, the country whose actions compelled the international community to finally complete efforts to rewrite one of the few global health treaties did not offer its experience or expertise to these efforts—not even as a cautionary tale of what states should avoid doing when facing a previously unknown infectious disease. This reluctance extends to other health-related treaties, too. During the negotiations that crafted the Framework Convention on Tobacco Control, Lee et al. interpret China’s involvement as driven more by industry interests rather than broader public health concerns. China is both the largest producer and largest consumer of tobacco products (Lee et al. 2012: 353). By promoting the concerns of tobacco companies over larger public health interests, China again demonstrated its ambivalent attitude towards the international society of global health governance—though it was not the only country that tried to protect its tobacco industry in the face of criticism of smoking. While there certainly is space to criticize China’s reluctance to engage with the institutions of global health governance within international society, China has not completely shunned these institutions. Indeed, it is entirely plausible to argue that the government has taken a number of steps to demonstrate its interest and willingness to embrace the norms and values embedded within this regime. China may not be the most active member of WHO, but that does not mean that it wholly dismisses the organization’s importance. There is no clearer sign of its willingness to engage with WHO than Dr Margaret Chan, WHO’s Director-General from 2007 to 2017. Chan began her public health career when she became a medical officer with the Hong Kong Government in 1978. She progressed through the ranks of the Hong Kong Department of Health to eventually become its leader in 1994. She joined WHO in 2003 and 147

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worked on issues like promoting healthy workplace environments, pandemic influenza, and infectious disease surveillance before being elected WHO Director-General. What is significant about Chan’s position is that the Chinese government actively promoted her candidacy and gave her its full backing (People’s Daily 2006b). Analysts took different views of why China would decide to get so involved in an organization that it had previously afforded relatively little attention. On the one hand, China’s actions could be perceived as recognition that working with WHO is the best way to help craft the norms and values underlying global health governance within international society. Lo notes, ‘The presence of Margaret Chan—a Chinese citizen—as DirectorGeneral of WHO could give China even more of an opportunity to become the leader in global health governance’ (Lo 2010: 23). Working with the organization from the inside gives China a place at the table, helping it to craft the regime in a way that resonates with its beliefs and bolster its status as a responsible great power. On the other hand, the move could be interpreted as a cynical attempt to block future reforms. After the criticism China received for its handling of SARS, it may have feared being sanctioned by WHO or being subject to more intrusive surveillance efforts. It may have also feared that its own poor relations with WHO during the SARS outbreak could give Taiwan leverage in its efforts to join WHO on its own. By installing one of its own citizens as Director-General, China could theoretically prevent WHO from introducing policies that would challenge China’s sovereignty (Chan 2011: 120). While it is impossible to know the Chinese government’s exact motivation, it is worth noting that China’s increased engagement with WHO is in line with its general trend of joining international organizations and signing up to various treaties and cooperation agreements (Chan et al. 2012: 107). China’s approach to global health governance has evolved considerably since the 1960s when it started deploying medical teams in developing countries. In the early days, China’s approach could be described as largely defensive. The medical teams were an effort to counter both the Soviet Union and the United States and build alliances with potentially friendly states. The country embraced a bilateral approach to global health issues, preferring to work in a one-on-one relationship with recipient states selected specifically because of their real or perceived strategic importance (Huang 2010: 107–10). Though China eschewed the multilateral approaches of the global health governance institutions within international society, it did not worry about being a responsible power within international society because ‘it regarded the international system as alien and illegitimate’ (Huang 2010: 110). Until the 1980s, then, it would be difficult to argue that China saw much, if any, value within global health governance. China’s attitude towards global health governance institutions starts to shift during the 1990s. Huang ascribes this change to the government developing a 148

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new sense of accountability and commitment to the international system, a desire to promote an image as an internationally responsible citizen, and a recognition of human security and non-traditional approaches to security (Huang 2010: 112–14). He also cites SARS as providing an impetus for further engagement with global health governance. The outbreak undermined the country’s long efforts to improve its international image and project an air of legitimacy and competency. As a result, the government eventually demonstrated a willingness to collaborate with WHO and regional Association of Southeast Asian Nations partners for health assistance because it recognized both that it lacked the necessary expertise to handle outbreaks on its own and that it had demonstrated its vulnerability. ‘In an age of globalization,’ Huang argues, ‘it [the Chinese government] can no longer monopolise information or act alone in addressing NTS [non-traditional security] challenges’ (Huang 2010: 121). China has demonstrated a new willingness to engage with regional and international partners to address health concerns, even if it may have some selfish motivations for doing so. Changes in China’s approach to foreign aid in the mid-1990s facilitated an increase in its DAH budgets. In 1995, the government moved beyond a singular focus on deploying medical teams to provide direct services in developing countries to allow for funding to support improving health infrastructure, developing health-related human resources, and delivering medical services. States that want to obtain such resources from China must make their request known through their local Chinese embassy, which can forward the request to Beijing. Interestingly, since the country lacks specific foreign aid laws, the approval process for health-related aid (or any other form of aid) proceeds in an ad hoc manner and takes one to two years (Huang 2014: 185–90). In general, the Ministry of Foreign Affairs determines the amount of aid to be granted and works with the Ministry of Commerce to make plans for aid disbursement and ensure that political interests are not subordinated to commercial ones. Meanwhile, the Ministry of Finance takes the lead on bilateral and multilateral aid initiatives, and the Ministry of Health oversees the deployment of medical teams. The Global Health Diplomatic Coordination Office works to facilitate cooperation and communication among these different ministries (Florini et al. 2012: 341). Within the language of any agreement to provide DAH to a developing state, the Chinese government highlights its sensitivity towards sovereignty, emphasizing that the recipient government is ultimately responsible for making policy decisions (Tan et al. 2014: 327). China finds itself in an interesting position within the global economy and global health governance. The sheer size of its economy raises expectations about significant contributions to various international organizations and health campaigns. On a per capita basis, though, China is a middle-income country. It is precisely in these middle-income countries where the bulk of the 149

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world’s poor live and where the global burden of disease is shifting (Glassman et al. 2013: 2–5). While this means that middle-income states are likely to need additional resources from international society in order to address the health concerns of their citizens, their relative wealth means that many of them are no longer eligible for funding from leading global health governance institutions (Glassman et al. 2013: 6). Economic growth in countries like China increases the pressures on governments to address health concerns, but this occurs at the very time when they are eligible for less funding. It is into this gap that China aims to step. The country finds itself as both a donor of DAH and a recipient of that same aid. China is the most significant foreign aid donor that is not a part of the Organisation for Economic Cooperation and Development’s (OECD) Development Assistance Committee (DAC) (Harman and Williams 2014: 935). DAC member-states are the traditional aid donors, and they are required to have a framework for providing development assistance and engage in monitoring and evaluation activities of their efforts (Organisation for Economic Cooperation and Development n.d.). They have traditionally given the bulk of foreign aid, but this has shifted in recent years. In 2000, non-traditional sources provided 8.1 per cent of all foreign aid. In 2009, these same non-traditional sources were the source of 30.7 per cent of all foreign aid (Harman and Williams 2014: 935–6). This change in which states provide foreign aid means both that more states are trying to demonstrate that they have an interest in being seen as responsible members of international society and that international society itself may be changing to better accommodate these new players. Before looking at China’s aid flows, it is important to establish that any reported figures are essentially educated estimates based on information culled from a wide variety of sources. It is not that the Chinese government does not account for the total amount that it disburses in foreign aid; rather, foreign aid is part of a tightly controlled government budget reporting system (Brautigam 2009: 166). There are a number of reasons for this. Brautigam cites continued diplomatic tensions with Taiwan, a sense of impropriety in calling attention to delivering assistance, and disagreements over whether China is too poor to give aid to others (Brautigam 2009: 165–6). Florini et al. write, ‘It is more difficult to obtain credible estimates of China’s overseas aid, given domestic political sensitivities in both Beijing and among its aid recipients about publicising aid flows, inadequate inter-ministerial information sharing and limited aid expertise in Beijing, and the absence of a clear development aid system and lexicon within the Chinese government’ (Florini et al. 2012: 338). Drawing on a variety of sources, Florini et al. derive estimates for China’s DAH for 2007 and 2008. They peg the country’s DAH commitments at slightly more than $300 million. The overwhelming majority of funds went to recipient 150

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states on a bilateral basis. WHO received $18 million, the UN health apparatus received $15 million, and the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) received $2 million. Not all of this aid was in cash; a significant portion of it came as in-kind services (Florini et al. 2012: 339–40). China’s contribution to the Global Fund is particularly interesting. In the same year that the Chinese government gave the Global Fund $2 million, it received $1 billion from the same organization (Florini et al. 2012: 340). The fact that China is giving money to global health organizations like the Global Fund when it is receiving funding from them suggests that its contribution may largely be premised on establishing patterns and demonstrating an interest in participating in international society’s global health institutions. Given the country-ownership requirements attached to Global Fund grants, it is clear that China needs the funding from the organization to carry out various programmes. That said, providing some small amount of funding to a multilateral global health organization represents a good faith effort to participate in the organs of global health governance. At this point, though, China has ‘benefited substantially from multilateral initiatives to which their material contributions have been limited and their ideational contributions nonexistent’ (Florini et al. 2012: 345). It is notable that China’s DAH overwhelmingly goes through bilateral, as opposed to multilateral, channels. It is on the extreme end of the spectrum, but this is not entirely out of step with the rest of the international community. Korea, Portugal, Germany, and Japan all funnel more than 40 per cent of their global health funds through bilateral channels (Institute for Health Metrics and Evaluation 2015: 20). China’s preference for bilateral channels may reflect its relative newness to the DAH realm, its unsettled foreign aid bureaucracy, its interests in increasing the sovereign capacities of its recipient states, and its concerns about the role of civil society organizations and NGOs in service delivery (Florini et al. 2012: 342–5; Huang 2010: 123–9). As with the deployment of medical teams as part of its health diplomacy strategy, China’s engagement with global health governance within international society embodies a dual insider/outsider strategy. The government has expressed an interest in being a member of international society and taken tentative steps towards active engagement, but it remains a bit aloof to preserve some measure of independence and so that it can portray itself as a bulwark against imperialism and Western hegemony.

Conclusion Without the involvement of the PRC, the global health governance system within international society will have a serious gap. Given its epidemiological 151

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history, the sheer size of its population, and its economic wealth, China is obviously an important element in creating and maintaining sustainable strategies to prevent and stop the spread of future epidemics. At the same time, it is of utmost importance that international society be willing to adapt and evolve in such a way that makes it more inclusive of non-Western states. In many ways, China’s approach towards global health governance mirrors the pluralist conception of international society: state-centric, minimal in its obligations and shared norms, respectful of sovereignty, and a tool for achieving certain specified goals. As much of global health governance walks the line between pluralism and solidarism, this does not necessarily put China’s position far outside the bounds of international society and suggests that international society may possess the adaptability that will facilitate the normative evolutions that will ease China’s full entry into international society. Perhaps the area of greatest contention will emerge regarding the role of non-state actors such as NGOs and civil society organizations in the provision and maintenance of the global health governance architecture. This is an area that potentially strikes at the heart of the Chinese government’s conception of its own power and legitimacy. That said, and this is important to recognize, the role of non-state actors also challenges some of the base assumptions in English School theorizing of international society. Much in the same way that the Chinese government will likely need to identify ways that it can productively partner with non-state actors in support of global health governance, English School theorizing about international society needs to open itself to recognizing the important role that non-state actors play in the contemporary arena when it comes to the promulgation and support of norms, values, and standards within international society. In this way, China’s stance is less of an outlier position and more a reflection of the theoretical blind spot that currently exists within international society.

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Global health governance plays an important and significant role in international society. It exists as a secondary institution contributing to the emerging primary institution of moral obligation and responsibility. Supporting cooperative efforts to address cross-border health concerns—even when those issues do not have a direct effect on an actor’s economic or security interests—has become a constitutive element of what it means to be a good international citizen and a member in good standing of international society. It has a constitutive effect on international society, as it shapes the normative and behavioural expectations, patterns, and identities of its members. Since the beginning of the 1990s, contemporary global health governance has assumed the status of a key institution that helps makes international life possible. It allows for elements of both order and justice within international society. It finds itself blending solidarism and pluralism as it responds to new issues and the emergence of new actors. With its origins going back to at least the middle part of the nineteenth century, the current manifestation of the institution of global health governance really took shape beginning around 1990 and has continued to develop since then. Global health governance’s evolution has also highlighted the growing importance of international political economy and non-state actors to understanding how and why international society functions. More importantly, the seriousness attached to global health governance is reflective of an even larger shift within international society towards the embracing of moral responsibility and obligation as key elements of the system. These realities are important for four reasons. First, they show how the English School approach to international relations helps us to understand the emergence, growth, and persistence of global health governance. International actors care about global health governance—and not just for selfish reasons. Instead, understanding global health governance helps us to apprehend how international life happens and the ways in which it happens. Traditional intergovernmental organizations play a role, but they are not the

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only important actors. It has a constitutive effect on international society, but still allows for states to retain their sovereignty. It shows how there can be broad agreement of the general outlines of the institution of global health governance but with disagreements remaining about the specifics of how the various elements of global health governance operate. Second, they show how the English School would benefit from pushing its traditional analytical foci to include previously underappreciated elements of contemporary international society. For all of its theoretical innovation, the English School has largely avoided sustained engagement with international political economy. This may be the result of historical happenstance because of the academic inclinations of the theory’s founders, but it is an oversight that deserves correcting. International life today is hardly explicable without making reference to economic factors and decisions. Foreign aid and the global political economy are integral to international interactions. That is not to say that all actions are reducible to economic interests; rather, it is a recognition that economics are an important element for understanding how international life occurs. The contours of global health governance and the challenges it faces are difficult to understand if we do not account for economics. Similarly, the English School has tended to hold non-state actors at arm’s length. There has been an assumption that non-state actors cannot have a genuine effect on international politics unless and until a world society with universally shared values emerges. Implicit in this idea is the suggestion that recognizing the importance of non-state actors necessitates denigrating or reducing the role of states. Global health governance— and the primary institution of moral responsibility and obligation more generally—shows that non-state actors play a vital role in making international life possible. It does not mean that non-governmental organizations (NGOs), public–private partnerships, or private philanthropies can or should replace states. It does mean, though, that these non-state actors facilitate international action—and do so without requiring shared universal values as frequently implied by the literature on world society. English School theorizing would benefit from incorporating this more nuanced understanding of how non-state actors are involved in international society into its analysis. Third, they show the importance of paying attention to secondary institutions in international society. Secondary institutions are more than formal organizations. They possess their own discursively formulated expectations that have a constitutive effect on international society. They help to make particular elements of primary institutions possible. They may be more temporally and spatially specific than primary institutions, but in that way, they can provide differentiated roles to actors, explain the relationships among different actors, and define ideas, interests, and capabilities more directly 154

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than primary institutions can. This broader understanding of secondary institutions is vitally important. We have to understand the interactions of these more temporally and spatially specific organizations in order to understand the institution of global health governance as a whole and how they contribute to realizing the precepts of the primary institution of moral responsibility and obligation. They work in conjunction with one another. More broadly, there is a value in not relegating secondary institutions to other theoretical frameworks; they have a place in the English School, and English School methods can help us understand how and why they operate in the ways in which they do. Finally, they show us the value of using a firm theoretical framework for understanding global health governance. Too infrequently, the global health governance literature has shied away from positioning itself within the broader realm of international relations theory. This is unfortunate for the literatures on both global health governance and international relations theory. Global health can inform international relations theory in a myriad of ways. At the same time, analysing global health governance in an atheoretical manner deprives it of analytical staying power and the ability to look at issues in the longer term. Instead, it leads to analysis that too often jumps from crisis point to crisis point without having a sense of the ‘big picture’. This does not imply that the English School is the only theoretical lens for understanding global health governance. Instead, it suggests that positioning global health governance within an English School framework provides my argument with the opportunity to see how the institution operates within international society over the long term and not simply in response to annual fluctuations in development assistance for health or responses to particular disease outbreaks.

The Future of Global Health Governance Global health governance has changed dramatically since 1990, and it will continue to evolve and change going forward. While international relations theory and past practice do not provide us with a crystal ball to predict the future, we can draw on their insights to suggest how the institution may change in the near future. First, it is likely that global health governance will continue its emphasis on infectious diseases. Non-communicable diseases are unlikely to receive increased attention or resources, nor are more general efforts to strengthen health systems more broadly, in the near future. This does not mean that these issues are unimportant, but it does mean that they have not yet found a hook or powerful advocates who can encourage international society to alter the 155

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ways in which it prioritizes these issues. The continued emphasis on infectious diseases, though, may have a positive spillover effect in creating more robust response capacities to disease outbreaks. The failures in responding to Ebola will likely prompt some sorts of changes that get resources to disease outbreaks in a quicker manner or reorient decision-making procedures to reduce the lag time between the recognition of an outbreak and the response. Second, states and non-state actors will both continue to have prominent and complementary roles to play in global health governance. As this almost symbiotic relationship continues and deepens, it is likely that better coordinating mechanisms to connect them in an ongoing, sustained manner will develop. As it currently stands, the relationship between states and non-state actors operates in a rather ad hoc manner, and there are actors on both sides who are wary of the other’s intentions or trustworthiness. Given that neither states nor non-state actors will abandon the global health governance space any time soon, there will be a need to develop a better forum for bringing them together. The existing frameworks for bringing state and non-state actors together on global health governance issues tend to be driven by the interests of states or intergovernmental organizations, but this is unlikely to prove satisfactory or efficient going forward. This is particularly important, as ongoing socialization efforts will benefit both sides and make international society operate more efficiently. Third, the diversity of organizations involved in global health governance is likely to expand. The World Health Organization retains its constitutional mandate to direct and coordinate international health efforts, but it is unlikely to acquire the unfettered resources necessary to really top the global health governance hierarchy. Instead, its role will increasingly become that of a coordinator among an ever-expanding range of actors in the global health space. The BRICS states—Brazil, Russia, India, China, and South Africa—may take a greater role in global health governance, either as donors or through more sustained engagement with health-related intergovernmental organizations. New intergovernmental organizations like the African Union Centres for Disease Control and Prevention and the Asian Infrastructure Investment Bank have the potential to have a large role in global health governance. Private philanthropies are also likely to become even more prominent, as the BMGF’s wealth continues to grow and the Chan Zuckerberg Initiative starts making its first grants. The increasing range of actors involved in global health governance will likely, in some ways, make WHO even more important as a facilitator and mediator. It can use its legitimacy to foster ties among other organizations to actually implement various campaigns and provide funds for addressing issues. Finally, the issues facing global health governance are likely to increase in their complexity. Part of this is due to the emergence of new pathogens. When new diseases appear, international society not only has to try to stop their 156

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spread but also conduct scientific research to understand their nature, origin, and treatment. Part of this is due to the increased likelihood of diseases spreading across borders. The Ebola outbreak in West Africa, like the SARS outbreak before it, showed how the ease of travel increases the likelihood that disease outbreaks will affect multiple countries simultaneously, which makes the involvement of global health governance both more important and more difficult to navigate. Complexity may also come from the efforts to navigate the tricky realm of intellectual property rights in order to provide broader access to pharmaceuticals, vaccines, and other medical treatments. More complex concerns will further increase the importance of creating effective means for various actors to collaborate on global health matters. Ultimately, the emergence, growth, and resilience of global health governance as a secondary institution within international society raises larger questions about the potential development of shared universal values. If global health governance has proven itself so persistent in the face of numerous challenges, incorporated a wide range of actors into its various structures, and become a major site for official development assistance, does this suggest that we are witnessing the nascent stages of the full-fledged emergence of world society? Is global health governance evidence of the vitality of at least some set of shared universal values? While global health governance’s rise over the past generation is undoubtedly good news for the international community and has helped promote better health and cooperation on health issues, it is likely a bridge too far to say that it equates to the emergence of world society on a grand scale for three reasons. One, world society itself remains relatively undeveloped as a concept within English School theory (Buzan 2001). Williams laments, ‘One searches vainly for a clear, accepted definition [for world society] such as those provided by Bull for an international system and an international society’ (Williams 2005: 20), and Clark calls the concept ‘remarkably slippery’ (Clark 2007: 6). As a result, there remain significant levels of ambiguity as to what would actually provide proof of the ascendance of world society. Two, if we accept the idea that world society’s analytical focus pays particular attention to the political activity of individuals as opposed to states and assumes normative progress is happening on universal terms (Williams 2005: 20), then we must recognize that much, if not most, of the political activity happening within the global health space is still concentrated on and within organized entities. Global health’s political activity understands and respects the role of individuals; indeed, the emergence of a human rights orientation towards issues like HIV/AIDS is one of the hallmarks of the transformation in the international community’s approach to health (Youde 2011b). That said, the role of individuals is largely mediated through organized institutions, and it is the operation of these organized institutions that constitutes the 157

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major focus of most global health governance work. Three, world society and international society are not necessarily in opposition to one another. World society and international society both operate within any given political system that has developed to the point of actually being a society. The nature of the relationship between the two is ever-changing along a spectrum ranging from high degrees of overlap to near-total rejection of each other (Pella 2015: 213). Phrasing the question in terms of whether world society is replacing international society thus misses the point, especially when we are talking about institutions that are still relatively nascent. Instead, taking a lead from Clark (2007), it is better to consider how the norms and values within international society interact with and are affected by the various actors working within a specific issue space. Global health governance is not proof of the triumph of world society over international society, but it does provide insights about how this secondary institution is having an effect on both the international society and world society strands of contemporary international relations. These insights help us to recognize that global health governance is helping to transform values and ideas, but it itself likely does not function as a shared universal value. Four elements of this relationship are particularly important. First, global health governance has provided a space for marginalized groups and those whose health concerns had not previously received attention to have a political voice. While this voice often finds its expression through institutions, those organizations have faced significant pressures from activists, NGOs, and other non-state actors. The high levels of funding for HIV/AIDS programmes in global health are not simply the result of the beneficence of donor states; they have developed over the past twenty years because states have felt direct and continual pressure from groups representing those living with and affected by the disease (Epstein 1996; France 2016; Robins 2004). This sort of interaction—where non-state actors can take advantage of the spaces for political organizing provided by world society to put pressure on organizations and states operating within international society—is exactly the sort of relationship between these two spheres as envisioned by Williams (2005). Second, the dynamics of and potentially conflicting imperatives between international society and world society allow for a diversity of understandings and opinions on global health issues. Global health governance has become a secondary institution within international society, and one of the reasons it still finds its expression largely within international society is that the mere existence of the institution itself has not resolved debates about how the institution should operate. The Chinese government, WHO, and the Bill and Melinda Gates Foundation share a common belief that the international community needs to address cross-border health issues—but they have different interpretations of how exactly those issues should be addressed. 158

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Third, as Hurrell (2001) reminds us, institutions are more than simple rational and technocratic enterprises to carry out specific purposes. Instead, they represent norms and values that exist in the larger international system and are reflected in the operation and design of various organizations. They provide a space for considering questions of power, values, and legitimacy without specifying a particular answer. By extension, the fact that global health governance is a secondary institution within international society allows us a space to consider what a shared universal understanding of the ideas may look like without telling us how or whether such shared values should emerge. Instead, it continues earlier English School debates over whether the international system can achieve ‘consensus on ideas of the good that might guide member states not only to more security, but also to a more just practice’ (Cochran 2009: 219). Finally, limiting global health governance embraces a diverse array of frames that motivate normative action within international society. Bain argues that the English School frequently finds its normativity stymied by its failure to adequately explain the underlying basis for an obligation within international life. While theorists and activists may make appeals to obligations to international action based on shared humanity, Bain finds these unsatisfying because they ‘presuppose an (unacknowledged) antecedent source of value that endows “humanity” with its moral character’ (Bain 2007: 561). He suggests that it is not enough to say that actors are obligated to address an international issue—like, for instance, global health governance—simply because we are all human because that leaves the nature and imperative of the response subject to too many potential whims. This has been an issue within the global health governance space, as the justifications offered for supporting the secondary institution vary widely. Global health governance has been framed in a wide variety of ways—as a security issue, an economic issue, and a human rights issue, among others. These different frames appeal to different actors on different issues—and that is probably a good thing. A single shared understanding of what global health governance means and why it is important would undermine the diversity that actually gives rise to the institution in the first place. International society will continue to face serious cross-border health challenges in the future. We may see the re-emergence of pandemic influenza (McInnes et al. 2014: 41–58). We may see new diseases appear in the human population (Zacher and Keefe 2008: 44). We may see increased health threats associated with the increase in antimicrobial resistance around the world (Osterholm and Olshaker 2017). We may confront the spectre of zombieism spread through direct person-to-person contact (Youde 2012). Whatever it is, the secondary institution of global health governance, related to a larger primary institution of moral obligation and responsibility, is a necessary 159

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element for fostering international society’s response. As such, global health governance shapes behavioural and normative expectations, fosters cooperation, and gives meaning and definition to the roles, interests, and identities of actors within the system. It brings a sense of both order and justice to the international realm and helps make international life possible. It brings together a wide range of actors who agree about the importance of working together to address cross-border health issues, even if they do not always agree on the specifics of how best to respond in all circumstances. If we want to understand the role of global health governance within the broader arena of international relations, the English School provides a useful theoretical framework for doing so.

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Index

Africa 10, 102, 104, 132, 135, 140, 141–5 China 141–5 health diplomacy 141–5 African Union 143 African Union Centre for Disease Control and Prevention 143, 156 AFRO see Regional Office for Africa AIDS see HIV/AIDS Algeria 141 ‘all-risks’ approach 66–7 Allen, Paul 2, 125 Ebola 125 Alma-Ata 62–3 antimicrobial resistance 159 antiretroviral therapy (ART) 26, 73, 77, 85, 104–5 funding for 73, 77, 104–5 Arab League 48 Arab Maghreb Union 48 ART see antiretroviral therapy ASEAN see Association of Southeast Asian Nations Asian Infrastructure Investment Bank 156 Aspen Medical 125 Association of Southeast Asian Nations (ASEAN) 149 Australia 125 Ban Ki-moon 91 basic subsistence rights 3, 15, 20, 27–8, 42, 45, 62 bed nets 85, 105–6 Bill and Melinda Gates Foundation (BMGF) 2, 8, 19, 26, 51, 71–4, 82, 84, 86, 88, 92–3, 106, 109, 110–11, 125, 156, 158 controversies 72–4 criticisms 73–4 development assistance for health (DAH) 19, 71–3, 92, 110–11 Ebola 73, 125 GAVI Alliance 86 Global Fund to Fight AIDS, Tuberculosis, and Malaria 72, 84 Global Health Program 71

Institute for Health Metrics and Evaluation 73 health systems strengthening (HSS) 109 legitimacy 74 malaria 73–4, 93 tuberculosis 106 wealth 71 World Health Organization 73 Bloomberg Philanthropies 92, 108 BMGF see Bill and Melinda Gates Foundation Bono 88, 90–1 ‘brain drain’ 110 Brazil 60, 134, 156 BRICS (Brazil/Russia/India/China/South Africa) 134, 156 British Committee on the Theory of International Politics 12, 23 Buffett, Warren 71 Bull, Hedley 12, 13–14, 25–6, 27, 28, 33–4 Butterfield, Herbert 12 Buzan, Barry 20, 27–8, 34–7 Canada 85, 98 Cape Verde 144 Carter, Jimmy 91 Carter Center 89 CCMs see Country Coordinating Mechanisms CDC see Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC) 2, 105, 111 Chan, Margaret 97, 115, 121, 124, 130, 133, 147–8 Chan, Priscilla 111 Chan Zuckerberg Initiative (CZI) 111, 156 China 2, 6, 9–10, 28–9, 63, 94, 125, 132, 133–52, 158 Africa 141–5 Chan, Margaret 147–8 civil society organizations 139, 151 development assistance for health (DAH) 135, 138–9, 149–51 Ebola 125, 144–5 economy 135, 138–9

Index China (cont.) English School 139–40, 152 Five Principles of Peaceful Coexistence 139 foreign aid 134, 139, 149–51, 154 Forum on China–Africa Cooperation (FOCAC) 142–4 Framework Convention on Tobacco Control 147 Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) 151 global health governance 133–52 globalization 149 health diplomacy 10, 140, 141–5, 148 intergovernmental organizations (IGOs) 138 International Health Regulations (IHR) 146–7 international society 9–10, 134, 135–40, 144–5, 151–2 Millennium Development Goals (MDGs) 144 nationalism 146 non-governmental organizations (NGOs) 139, 151–2 Organization for Economic Cooperation and Development 150 People’s Liberation Army 144–5 severe acute respiratory syndrome (SARS) 148, 149 sovereignty 138, 139, 146, 148 standard of civilization 135–7 Taiwan 150 United Nations (UN) 151 United Nations peacekeeping operations 139, 144–5 World Bank 139 World Health Organization (WHO) 133, 146–9, 151 cholera 51–6, 65, 119 blame for 52, 54 causes 51–2 contagion theory 54 effects on commerce 53–5, 56 Guinea 119 India 52 International Health Regulations (IHR) 65 International Sanitary Convention 56 International Sanitary Regulations (ISR) 65 Koch, Robert 54 miasma theory 54 mortality 52 origins 52 quarantine 53, 55 supernatural theory 55 theories about 54–5 civil society organizations 22–3, 25–6, 68, 84, 86, 109, 127, 139, 151 Clinton, Bill 91, 92

186

Clinton Foundation 26, 92 Cold War 38, 61, 64, 136, 141 complex governance 25–6 contagion theory 54 Convention on the Prevention and Punishment of the Crime of Genocide 47 cosmopolitanism 9, 23, 24, 40, 47 Côte d’Ivoire 118 Council on Foreign Relations 96–7 Country Coordinating Mechanisms (CCMs) 69–70 CZI see Chan Zuckerberg Initiative DAC see Development Assistance Committee DAH see development assistance for health Declaration of Alma-Ata 63–4 decolonization 62–3 democracy 19, 37, 39, 43, 44, 59, 136 development 6, 26, 29–30, 44–5, 50, 63, 68–9, 81–2, 92, 96–7, 99, 101–2, 108, 112, 134, 141, 142, 145, 150, 157 Development Assistance Committee (DAC) 150 development assistance for health (DAH) 6, 8, 9, 19, 26, 29, 94, 95–114 Bill and Melinda Gates Foundation (BMGF) 110–11 Canada 85, 98 Chan Zuckerberg Initiative 111 China 149–51 Council on Foreign Relations 96–7 East Asia 102 global financial crisis 97–100 health systems strengthening 100, 109–10 HIV/AIDS 101–2, 102–5 horizontal programs 100 Institute for Health Metrics and Evaluation (IHME) 97 international political economy 113 international society 99, 112, 113–14 issue-areas 100–10 Japan 98, 151 Latin America and the Caribbean 102 malaria 102, 105–6 maternal health 102 Netherlands 98 newborn and child health 102 non-communicable diseases (NCDs) 101–2, 108–9 non-governmental organizations (NGOs) 97 non-state actors (NSAs) 110–12 normative expectations 112 Oceania 102 Organization for Economic Cooperation and Development (OECD) 96, 99–100 phases 97 pluralism 113

Index private actors 97 private business 111 public private partnerships (PPPs) 111–12 solidarism 113 Southeast Asia 102 Spain 98 sub-Saharan Africa 102 trends 96–100 tuberculosis 102, 106–8 United States 71, 98, 104, 105, 106 vertical programmes 101 World Bank 96 World Health Assembly (WHA) 98 diplomacy 3, 4, 6, 13, 28–9, 34–6, 39 see also health diplomacy Doctors Without Borders see Médecins Sans Frontières Doha Round 90 Duncan, Thomas Eric 119 Ebola 1–3, 9, 20, 26, 43, 65, 67, 73, 78, 81, 89, 94, 100, 111, 115–32, 143, 145, 156–7 Allen, Paul 125 animal vector 118 Aspen Medical 125 Australia 125 Bill and Melinda Gates Foundation 125 case reporting 115, 118–19 China 125, 143, 145 containment 117–18 costs 123–4 Côte d’Ivoire 118 funding 111, 122–3 Germany 125 global health governance 115–32 Guinea 115, 116, 118–19 health systems 100, 118 intergovernmental organizations (IGOs) 116 International Committee of the Red Cross (ICRC) 124 International Health Regulations (IHR) 65, 119, 121 international political economy 116 international society 120–6 Liberia 115, 116, 119 Mali 119 Médecins Sans Frontières (MSF) 120, 124, 125–6 military 125 mortality 115, 117 Nigeria 120 non-governmental organizations (NGOs) 116, 120, 124–6 philanthropic organizations 116 Public Health Emergency of International Concern (PHEIC) 121–2 Regional Office for Africa (AFRO) 122, 123–4

response 78, 81, 116, 120–6, 127–31 Samaritan’s Purse 126 Serving in Mission (SIM) 126 Sierra Leone 115, 116, 119 states 116 Sub-Regional Outbreak Coordination Centre 121 transmission 117–18 treatment 117–18, 125 Uganda 118 United Kingdom 125 United Nations Mission for Ebola Emergency Relief (UNMEER) 1, 122, 123, 124 United States 2, 119, 125 West Africa 117–20 World Health Organization (WHO) 9, 78, 116, 118–19, 120–4, 127–30 Ebola Interim Assessment Panel 127, 128–9 Ebola Treatment Units (ETUs) 125 ECOSOC see United Nations Economic and Social Council English School 3–4, 5–10, 11–31, 32–50, 113–14, 139–40, 152, 153–60 China 139–40, 152 core beliefs 12–13 expansion of 20–9 global health governance 3–4, 5–10, 11, 30–1, 32, 48, 152, 153–60 history 12, 23 international political economy 11, 26–9, 31, 45, 154 international society 13, 154 international system 13 institutions 33 non-state actors 11, 21–6, 154 normativity 13 primary institutions 3, 33, 34–5, 38, 39–46, 154–5 regime theory 36–7 secondary institutions 3, 4, 7, 33, 35–9, 46–8, 154–5 shortcomings 11 world society 13, 154, 157 environmentalism 3, 42–3 ETUs see Ebola Treatment Units European Union 25, 138 extensively drug-resistant tuberculosis (XDR-TB) 107–8 Facebook 111 FCTC see Framework Convention on Tobacco Control Five Principles of Peaceful Coexistence 139 FOCAC see Forum on China–Africa Cooperation foreign aid 6, 9, 21, 26–7, 29, 30–1, 64, 96, 99, 112, 134, 139, 149–51, 154

187

Index foreign policy 16, 25, 133–5 Forum on China–Africa Cooperation (FOCAC) 142–4 Framework Convention on Tobacco Control (FCTC) 147 France 54, 60, 106, 119 G8 see Group of Eight Gates, Bill 71–2, 91, 92 Gates, Frederick 58 Gates, Melinda 71 Gates Foundation see Bill and Melinda Gates Foundation GAVI Alliance 82, 86, 111 Germany 106, 125, 151 Ghana 121 Global Alliance for Vaccines and Immunization see GAVI Alliance global financial crisis 98–100 Global Fund see Global Fund to Fight AIDS, Tuberculosis, and Malaria Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) 8, 51, 67–71, 72, 76, 81, 84–5, 97, 106, 111 Bill and Melinda Gates Foundation 72–3, 84 Board of Directors 84 China 151 civil society 68 corruption 85 Country Coordinating Mechanisms (CCMs) 69–70 funding 84–5, 97 HIV/AIDS 68–71, 84–5, 97 limitations 70 malaria 68–71, 84–5, 97, 105–6 non-governmental organizations (NGOs) 70, 84 operations 69 origins 68–9 Product (RED) 84 successes 69–70, 85 Tahir Foundation 84 Technical Review Panel 84 tuberculosis 68–71, 84–5, 97, 106 United Methodist Church 84 global health governance 3–6, 11–12, 29, 43, 75–94, 112–13, 115–32, 133–5, 140, 141–51, 153–60 actors 49, 75–94 Brazil 134 China 133–52 complexity 156–7 Ebola 43, 116 English School 3–4, 5–10, 11, 30–1, 32, 48, 152, 153–60 evolution of 6–7 framing 159

188

India 134 international society 93–4, 112–14, 130–1, 153, 156–7, 158 quarantine 50 Russia 134 non-communicable diseases 155–6 non-governmental organization 89–90 non-state actors (NSAs) 156 secondary institutions 30, 74, 95, 112–13, 116, 131–2, 153, 157 South Africa 134 states 76–7, 156 world society 158 Global North 28, 41–2, 45, 70, 87, 110 Global Polio Eradication Initiative 89 Global Programme on AIDS (GPA) 89, 90, 103 Global South 28, 41–2, 70, 87, 110 globalization 4, 27–8, 40–1, 51, 149 Gonzalez-Pelaez, Anna 20, 46 GPA see Global Programme on AIDS Group of Eight (G8) 68 Guinea 1, 115, 116, 118–21 Guinea worm eradication 89 Gulf Cooperation Council 48 H1N1 67 Harvard Global Health Institute–London School of Hygiene and Tropical Medicine Independent Panel on the Global Response to Ebola 127–8 health diplomacy 10, 132, 135, 140, 141–5, 147, 148, 151 Africa 135, 141–5 China 10, 135, 141–5, 147, 148, 151 Health for All by 2000 8, 51, 62–4 Cold War 64 definition 63–4 health systems strengthening (HSS) 100, 109–10 Bill and Melinda Gates Foundation 109 development assistance for health (DAH) 109–10 non-governmental organizations (NGOs) 109–10 Helms, Jesse 90–1 HIV/AIDS 4, 65, 68–70, 72, 83, 85, 89–90, 95, 98, 100, 101–2, 102–5, 107, 109, 157–8 Africa 104 development assistance for health (DAH) 95, 100, 101–2, 102–5, 158 Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) 68–71, 84–5, 97 non-governmental organizations (NGOs) 89–90 prevention 104 successes 103–4 tuberculosis 107 World Health Organization 95

Index horizontal programmes 70, 100–1, 109, 113 HSS see health systems strengthening human rights 13, 17–18, 25, 28, 39, 41–6, 50–1, 62, 83–4, 87, 90, 102, 131, 136, 139, 157–9 humanitarian intervention 3, 11, 13, 15, 42–3 IAVI see International AIDS Vaccine Alliance ICJ see International Court of Justice IHD see International Health Division IHME see Institute for Health Metrics and Evaluation IHR see International Health Regulations India 28–9, 52, 134, 156 influenza see H1N1; pandemic influenza Institut Pasteur 119 Institute for Health Metrics and Evaluation (IHME) 73, 97, 99, 104, 108, 110–11 institutions 14, 32, 33, 50, 159 definition 33 international society 50 International AIDS Vaccine Alliance (IAVI) 86 International Commission on Epidemics 55–6 International Committee of the Red Cross 124 International Conference on Primary Health Care 62–5 International Convention on Economic, Social, and Cultural Rights 62 International Convention on the Suppression and Punishment of the Crime of Apartheid 47 International Court of Justice (ICJ) 35 International Health Conference 60–1 International Health Division (IHD) 58–60, 91–2 League of Nations Health Office (LNHO) 59–60 International Health Organization 57 International Health Regulations (IHR) 8, 51, 56, 65–7, 90, 119, 121–2, 128, 146–7 2005 revision 66–7, 90, 119, 128, 147 ‘all-risks’ approach 66–7 China 146–7 criticisms 65–6 Ebola 65, 119, 121 Emergency Committee 122 limitations 67 non-governmental organizations (NGOs) 90 notifiable diseases 65 origins 65 Public Health Emergency of International Concern (PHEIC) 1, 9, 121–2, 127 requirements 66–7 revision process 66–7 severe acute respiratory syndrome (SARS) 66, 147 surveillance 65–6

international law 3–4, 17, 34, 41, 65, 136 International Monetary Fund 138 International Office of Public Hygiene see Office International d’Hygiène Publique (OIHP) international political economy 5, 11, 26–9, 31, 45, 96, 113, 116, 154 development assistance for health (DAH) 113 Ebola 116 English School 154 international society 96 primary institutions 27 international relations theory 5–6, 7, 12, 30 International Sanitary Bureau (ISB) 57, 60 International Sanitary Conferences (ISC) 8, 51, 51–6, 57, 65 France 54 Portugal 54 quarantine 53–4 Sardinia 54 International Sanitary Convention 56 International Sanitary Regulations (ISR) 65 international society 3, 11, 13, 23–4, 30, 31, 40–1, 120, 130–1, 135–40, 153, 156–7 China 9–10, 134, 135–40, 144–5 definition 13 democracy 43 Ebola 120–6 English School 154 environmentalism 11, 19, 42–5, 47 ethics 15–16, 18 global health governance 93–4, 112–14, 130–1, 153, 156–7 globalization 40–1 human rights 43 institutions 14, 34–5, 50 international political economy 96 interwar period 23 justice 16, 41 membership 14, 136–7 non-state actors 21–6, 47–8, 96 normativity 14–16 order 16, 41 pluralism 16–17, 19–20, 45–6 primary institutions 13–14, 18–19 secondary institutions 46–7 socialization 14–15 solidarism 16, 17–20, 45 sovereignty 146 standard of civilization 14, 136–7 world society 22–5, 158 international system 4, 9, 12, 13, 23, 30, 139, 146, 148–9, 157, 159 interwar period 23 ISB see International Sanitary Bureau

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Index ISC see International Sanitary Conferences ISR see International Sanitary Regulations Japan 68, 98, 135, 151 justice 16, 40–3 Kellogg–Briand Pact 23 Koch, Robert 54 Lassa fever 119 League of Nations 57–60 relations with League of Nations Health Office 59 League of Nations Health Office (LNHO) 8, 51, 57–60 budget 59–60 demise 59–60 International Health Division (IHD) 58–9 origins 58 relations with League of Nations 59 Rockefeller Foundation (RF) 58, 92 leprosy 53 Liberia 89, 115, 116–19, 121, 124, 126 Liu, Joanne 124 Liu, Zhenmin 144 LNHO see League of Nations of Health Office Mahler, Halfdan 63 malaria 68–70, 73–4, 85, 93, 102, 105–6 bed nets 105–6 DDT 106 development assistance for health (DAH) 105–6 Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) 68–71, 73, 84–5, 97, 105 non-governmental organizations (NGOs) 106 Parker Foundation 111 President’s Malaria Initiative (PMI) 105 successes 105–6 United States 105 Mali 119 Mann, Jonathan 89, 90 maternal health 102–3 McNamara, Robert 82 MDGs see Millennium Development Goals MDR-TB see multidrug-resistant tuberculosis Médecins Sans Frontières (MSF) 1, 26, 88, 90, 120, 121, 124, 125–6 Ebola 125–6 World Health Organization (WHO) 121, 124 miasma theory 54 Microsoft 71, 91, 92 Millennium Development Goals (MDGs) 44–5, 107, 109–10, 144

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moral responsibility and obligation 3, 11, 32, 39–46, 112–13, 131, 159–60 as a primary institution 11, 32, 39–46, 131, 159–60 international society 40 MSF see Médecins Sans Frontières multidrug-resistant tuberculosis (MDR-TB) 107–8 multilateral funding agencies 81–5 National Institutes for Health 98 National Science Foundation 98 NATO see North Atlantic Treaty Organization NCDs see non-communicable diseases neoliberalism 92–3, 101 Neves, Jose Maria 144 newborn and child health 102 NGOs see non-governmental organizations Nigeria 2, 120 non-communicable diseases (NCDs) 101–2, 108–9, 155–6 funding 108–9 global health governance 155–6 non-governmental organizations (NGOs) 108, 110–12 philanthropy 108 United Nations High-Level Meeting 108 World Health Organization 109 non-governmental organizations (NGOs) 1, 9, 19, 21–2, 26, 29, 47–8, 49, 57, 70, 76–7, 79–80, 87, 88–90, 106, 108, 110–12, 117, 120, 124–6, 130, 139, 151–2, 154, 158 Carter Center 89 China 139 development assistance for health (DAH) 110–12 Ebola 120, 124–6 Global Fund to Fight AIDS, Tuberculosis, and Malaria 70, 84 global health governance 88–9 health systems strengthening (HSS) 109–10 HIV/AIDS 89–90 International Health Regulations (2005) (IHR (2005)) 90 Liberia 89 malaria 106 non-communicable diseases 108 secondary institutions 48 World Health Organization 79–80, 130 non-state actors (NSAs) 6, 11, 18, 21–6, 31, 76, 87–93, 110–12, 154 development assistance for health (DAH) 110–12 English School 154 global health governance 156 international society 96 private foundations 110–12 relations with states 88

Index Nordic Council 48 North Atlantic Treaty Organization (NATO) 35, 38–9 NSAs see non-state actors OAU see Organization of African Unity Occidentalism 137–8 ODA see official development assistance OECD see Organization for Economic Cooperation and Development Office International d’Hygiène Publique (OIHP) 57–8, 60–1 official development assistance (ODA) 97–8 OIHP see Office International d’Hygiène Publique Opium War 137 order 16, 40–3 Organization for Economic Cooperation and Development (OECD) 96, 150 Development Assistance Committee (DAC) 150 Organization of African Unity (OAU) 68 PAHO see Pan American Health Organization Pan American Health Organization (PAHO) 57 Pan American Sanitary Bureau 60–1 pandemic influenza 148, 159 Parker, Alexandra 111 Parker, Sean 111 Parker Foundation 111 PEPFAR see President’s Emergency Plan for AIDS Relief People’s Liberation Army 144–5 People’s Republic of China see China PHC see primary health care PHEIC see Public Health Emergency of International Concern philanthropic organizations 26, 58–9, 71–4, 91–3, 108, 110–12, 154 advantages 92 Bill and Melinda Gates Foundation (BMGF) 71–4, 110–11 criticisms 92–3 non-communicable diseases (NCDs) 108 Rockefeller Foundation (RF) 58–9 Piot, Peter 72 plague 53, 54, 56, 65 pluralism 16–17, 19–20, 28, 40, 41, 45–6, 61, 113, 152, 153 PMI see President’s Malaria Initiative polio 2, 71, 89, 100 Portugal 54, 151 PPPs see public–private partnerships President’s Emergency Plan for AIDS Relief (PEPFAR) 98 President’s Malaria Initiative (PMI) 105 primary health care (PHC) 62–4

criticisms 64 definition 62–3 selective primary health care (SPHC) 64 primary institutions 3, 11, 13–14, 18–19, 27, 32, 33, 34–5, 38, 39–49, 154–5, 159–60 balance of power 34 definition 34, 36–7, 44 derivative primary institutions 36–7 differences with secondary institutions 36–7 diplomacy 34–5, 39 English School 3, 33, 34–5, 38, 39, 46, 154–5 great power management 34, 39 international law 34 international political economy 27 master primary institutions 36–7 moral responsibility and obligation 39–46, 131, 159–60 war 34 private actors 21, 29, 76, 77, 87–93, 110–12 Product (RED) 73, 84 Public Health Emergency of International Concern (PHEIC) 1, 9, 115, 121–2, 127 Ebola 115, 121–2 Regional Office for Africa (AFRO) 122 public–private partnerships (PPPs) 29, 76, 85–7, 107, 111–12, 154 criticisms 87 development assistance for health (DAH) 111–12 GAVI Alliance 86 International AIDS Vaccine Initiative 86 origins 86 tuberculosis 107 UNITAID 86 quarantine 50, 53–6, 65 R2P see Responsibility to Protect Ragusa, Republic of 53 Rajchman, Ludwik 59 regime theory 8, 32, 35–6, 37–8, 48 English School 37–8 secondary institutions 48 Regional Office for Africa (AFRO) 122, 123–4 relapsing fever 56, 65 Responsibility to Protect (R2P) 15, 44–5 RF see Rockefeller Foundation Rockefeller, John D., Jr 58 Rockefeller, John D., Sr 58–9 Rockefeller Foundation (RF) 58–9, 60, 88, 91–2 International Health Division (IHD) 58–9, 91–2 League of Nations Health Office (LNHO) 58–9, 92 World Health Organization 60 Rosling, Hans 124 Rotary International 71, 89

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Index Sachs, Jeffrey 88, 91 Samaritan’s Purse 1, 26, 126 Sardinia 54 SARS see severe acute respiratory syndrome Sawyer, Patrick 120 SDGs see Sustainable Development Goals secondary institutions 3, 4, 7, 11, 30, 32, 33, 35–9, 40, 46–8, 153, 154–5 constitutive effects 38–9, 47 definition 35–6, 38 differences with primary institutions 36–7 English School 3, 4, 7, 33, 35–9, 46–8, 154–5 global health governance 74, 95, 112–13, 116, 131–2, 153, 157, 158 importance of 46–8 international society 46–7 non-governmental organizations (NGOs) 48 regime theory 48 selective primary health care (SPHC) 64 Serving in Mission (SIM) 126 severe acute respiratory syndrome (SARS) 66, 147, 148, 149, 157 International Health Regulations (IHR) 147 surveillance 148 Sierra Leone 115, 116, 118, 119, 121 SIM see Serving in Mission smallpox 56, 65 socialization 14–15 solidarism 16, 17–20, 28, 40–1, 45, 61, 113, 152, 153 South Africa 89, 134, 156 sovereignty 4, 13, 15, 16, 17–18, 20, 34, 36, 42, 47, 61, 83, 138–9, 146, 148–9, 152, 154 China 139, 146, 148, 152, 154 Soviet Union 38, 64, 141, 148 SPHC see selective primary health care standard of civilization 14, 136–7 Standard Oil 58–9 statecraft 15, 28, 55 states 76–7, 156 global health governance 156 health spending 77 Stocking, Barbara 127 Stocking Report see Ebola Interim Assessment Panel Stop TB Partnership 100, 107 Sub-Regional Outbreak Coordination Centre 121 supernatural theory 55 surveillance 65–7, 90, 121, 125, 133, 143, 147–8 Sustainable Development Goals (SDGs) 45, 91 Tahir Foundation 84 Taiwan 148, 150

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Tanzania 63 Tarbell, Ida 59 TB see tuberculosis Treatment Action Campaign 88 tuberculosis 67–70, 82, 84–5, 100–2, 106–9 Bill and Melinda Gates Foundation 106 development assistance for health (DAH) 100–1, 106–9 extensively drug-resistant (XDR-TB) 107–8 France 106 Germany 106 Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) 68–71, 84–5, 97, 106 HIV/AIDS 107 Millennium Development Goals (MDGs) 107 multidrug-resistant (MDR-TB) 107–8 public–private partnerships (PPPs) 100, 107 treatment 82, 90, 107 United Kingdom 106 United States 106 World Health Organization (WHO) 107–8 typhus 56, 65 UN see United Nations UNAIDS 72, 103–5 UNICEF see United Nations Children’s Emergency Fund UNITAID 77, 86 United Kingdom 2, 60, 71, 106, 125 United Methodist Church 84 United Nations (UN) 1, 35, 39, 47, 60, 88–9, 139, 144–5, 151 peacekeeping operations 139, 144–5 United Nations Charter 60 United Nations Children’s Emergency Fund (UNICEF) 62 United Nations Economic and Social Council (ECOSOC) 88–9 United Nations Framework Convention on Climate Change (UNFCCC) 47 United Nations General Assembly 1, 68–9 Special Session on HIV/AIDS 68–9 United Nations High-Level Meeting 108 United Nations Mission for Ebola Emergency Relief (UNMEER) 1, 122, 124 United Nations Security Council (UNSC) 1, 122 United States 2, 58, 60, 71, 90–1, 98, 104, 105, 106, 119, 125, 138, 141, 148 Ebola 2, 119, 125 Universal Declaration of Human Rights 62 UNMEER see United Nations Mission for Ebola Emergency Relief UNSC see United Nations Security Council USSR see Soviet Union

Index Venezuela 63 vertical programmes 70, 100–1, 109–10, 113 Vincent, R. J. 15, 27, 28, 45–6 Warsaw Pact 38–9 Watson, Adam 12 Wellcome Trust 92 Wen Jiabao 134, 144 West Africa 1, 9, 20, 26, 78, 111, 114, 115–32, 145, 157 WHA see World Health Assembly WHO see World Health Organization Wight, Martin 12 World Bank 76, 77, 81–4, 96, 139 Bill and Melinda Gates Foundation 82 China 139 criticisms 82–4 GAVI Alliance 82 health 82–4 history 81–2 HIV/AIDS 83 McNamara, Robert 82 World Health Organization (WHO) 82, 83 World Health Assembly (WHA) 66–7, 79, 98, 126, 130 World Health Organization (WHO) 1, 3, 8, 60–1, 62, 73, 75, 76, 77, 78–81, 92, 95, 115, 120–4, 127–31, 149, 156, 158 antiretroviral therapy (ART) 104–5 Bill and Melinda Gates Foundation (BMGF) 73 challenges 78 Chan, Margaret 147–8 China 133, 146–9, 151 Constitution 61, 65, 78, 80 Director-General 79 Ebola 78, 115, 120–6 Ebola Interim Assessment Panel 127 Executive Board 79, 115 facilitation 78–9 funding 80, 97–8, 122–3 Global Programme on AIDS (GPA) 103 HIV/AIDS 95 information dissemination 78–9

international society 61 legitimacy 80–1 Médecins Sans Frontières (MSF) 121, 124 membership 61, 80 membership dues 80, 130 non-commuunicable diseases (NCDs) 109 non-governmental organizations (NGOs) 130 normative leadership 78–9 operations 78 origins 60–1 Public Health Emergency of International Concern (PHEIC) 121–2 reform 127–31 Regional Office for Africa (AFRO) 122 regional organizations 79 Secretariat 79 Sub-Regional Outbreak Coordination Centre 121 tuberculosis 107–8 voluntary contributions 80 World Bank 82, 83 World Health Assembly 79 World Trade Organization (WTO) 35 world society 13, 22–5, 40–1, 154, 157 English School 154, 157 global health governance 158 globalization 40–1 international society 158 interwar period 23 non-state actors 31 World Summit 44 World War I 57, 59 World War II 23, 59–60 XDR-TB see extensively drug-resistant tuberculosis Xi Jinping 144 yellow fever 56, 65 Zhou Enlai 141 zombieism 159 Zuckerberg, Mark 111

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